Obstetrics

Clinicians can consult a diagram to plan treatment of hypertension in diabetes patients as part of the new American Diabetes Association guidelines.

“Diabetes and Hypertension: A Position Statement by the American Diabetes Association” was published in the September 2017 issue of Diabetes Care, and online on Aug. 22. The statement updates the ADA’s previous statement on hypertension and diabetes published in 2003.

vitapix/Thinkstock

“Numerous studies have shown that antihypertensive therapy reduces ASCVD [atherosclerotic cardiovascular disease] events, heart failure, and microvascular complications in people with diabetes,” wrote Ian H. de Boer, MD, of the University of Washington, Seattle, and his colleagues.

The statement is a collaboration between nine diabetes experts from the United States, Europe, and Australia whose specialties include endocrinology, nephrology, cardiology, and internal medicine (Diabetes Care. 2017 Sep.;40:1273-84).

The statement recommends that diabetes patients have their blood pressure checked at every routine clinical visit and that those with an elevated blood pressure on a clinical visit (defined as office-based measurements of 140/90 mm Hg and higher) have multiple measurements, including on a separate day to confirm the diagnosis.

In addition, during the initial evaluation, and then periodically, diabetes patients should be assessed for orthostatic hypotension “to individualize blood pressure goals, select the most appropriate antihypertensive agents, and minimize adverse effects of antihypertensive therapy,” according to the recommendations.

For most patients with diabetes and hypertension, the goal should be a blood pressure below 140/90 mm Hg, and even lower targets may be appropriate for patients at high cardiovascular disease risk, the researchers said.

The guidelines include recommendations for managing hypertension and diabetes through lifestyle modifications such as increasing physical activity, achieving and maintaining a healthy weight, and following a healthy diet with minimal sodium intake and an emphasis on fruits, vegetables, and low-fat dairy products.

The guidelines also emphasize the need for caution when treating older adults who are taking multiple medications. “Systolic blood pressure should be the main target of treatment,” for adults aged 65 years and older with diabetes and hypertension, the authors said.

In addition, the guidelines provide direction for clinicians treating pregnant women. “During pregnancy, treatment with ACE inhibitors, ARBs [angiotensin receptor blockers], or spironolactone is contraindicated, as [these medications] may cause fetal damage,” the authors wrote. Pregnant women with preexisting hypertension or with mild gestational hypertension with systolic blood pressure below 160 mm Hg, a diastolic blood pressure below 105 mm Hg, and no sign of end-organ damage need not take antihypertensive medications, they said. For pregnant women who require antihypertensive treatment, the aim should be a systolic blood pressure between 120 mm Hg and 160 mm Hg and a diastolic blood pressure between 80 mm Hg and 105 mm Hg.

The authors concluded that there currently is insufficient evidence to support blood pressure medication for diabetes patients without hypertension.

The recommendations reference several key clinical trials that compared intensive and standard hypertension treatment strategies: the ACCORD BP (Action to Control Cardiovascular Risk in Diabetes – Blood Pressure) trial, the ADVANCE BP (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation – Blood Pressure) trial, the HOT (Hypertension Optimal Treatment) trial, and SPRINT (the Systolic Blood Pressure Intervention Trial).

Lead author Dr. de Boer reported serving as a consultant for Boehringer Ingelheim and Ironwood Pharmaceuticals, and his institution has received research equipment and supplies from Medtronic and Abbott. Study coauthors disclosed relationships with multiple companies including Merck, Abbott, Pfizer, and AstraZeneca.

Clinicians can consult a diagram to plan treatment of hypertension in diabetes patients as part of the new American Diabetes Association guidelines.

“Diabetes and Hypertension: A Position Statement by the American Diabetes Association” was published in the September 2017 issue of Diabetes Care, and online on Aug. 22. The statement updates the ADA’s previous statement on hypertension and diabetes published in 2003.

vitapix/Thinkstock

“Numerous studies have shown that antihypertensive therapy reduces ASCVD [atherosclerotic cardiovascular disease] events, heart failure, and microvascular complications in people with diabetes,” wrote Ian H. de Boer, MD, of the University of Washington, Seattle, and his colleagues.

The statement is a collaboration between nine diabetes experts from the United States, Europe, and Australia whose specialties include endocrinology, nephrology, cardiology, and internal medicine (Diabetes Care. 2017 Sep.;40:1273-84).

The statement recommends that diabetes patients have their blood pressure checked at every routine clinical visit and that those with an elevated blood pressure on a clinical visit (defined as office-based measurements of 140/90 mm Hg and higher) have multiple measurements, including on a separate day to confirm the diagnosis.

In addition, during the initial evaluation, and then periodically, diabetes patients should be assessed for orthostatic hypotension “to individualize blood pressure goals, select the most appropriate antihypertensive agents, and minimize adverse effects of antihypertensive therapy,” according to the recommendations.

For most patients with diabetes and hypertension, the goal should be a blood pressure below 140/90 mm Hg, and even lower targets may be appropriate for patients at high cardiovascular disease risk, the researchers said.

The guidelines include recommendations for managing hypertension and diabetes through lifestyle modifications such as increasing physical activity, achieving and maintaining a healthy weight, and following a healthy diet with minimal sodium intake and an emphasis on fruits, vegetables, and low-fat dairy products.

The guidelines also emphasize the need for caution when treating older adults who are taking multiple medications. “Systolic blood pressure should be the main target of treatment,” for adults aged 65 years and older with diabetes and hypertension, the authors said.

In addition, the guidelines provide direction for clinicians treating pregnant women. “During pregnancy, treatment with ACE inhibitors, ARBs [angiotensin receptor blockers], or spironolactone is contraindicated, as [these medications] may cause fetal damage,” the authors wrote. Pregnant women with preexisting hypertension or with mild gestational hypertension with systolic blood pressure below 160 mm Hg, a diastolic blood pressure below 105 mm Hg, and no sign of end-organ damage need not take antihypertensive medications, they said. For pregnant women who require antihypertensive treatment, the aim should be a systolic blood pressure between 120 mm Hg and 160 mm Hg and a diastolic blood pressure between 80 mm Hg and 105 mm Hg.

The authors concluded that there currently is insufficient evidence to support blood pressure medication for diabetes patients without hypertension.

The recommendations reference several key clinical trials that compared intensive and standard hypertension treatment strategies: the ACCORD BP (Action to Control Cardiovascular Risk in Diabetes – Blood Pressure) trial, the ADVANCE BP (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation – Blood Pressure) trial, the HOT (Hypertension Optimal Treatment) trial, and SPRINT (the Systolic Blood Pressure Intervention Trial).

Lead author Dr. de Boer reported serving as a consultant for Boehringer Ingelheim and Ironwood Pharmaceuticals, and his institution has received research equipment and supplies from Medtronic and Abbott. Study coauthors disclosed relationships with multiple companies including Merck, Abbott, Pfizer, and AstraZeneca.

Clinicians can consult a diagram to plan treatment of hypertension in diabetes patients as part of the new American Diabetes Association guidelines.

“Diabetes and Hypertension: A Position Statement by the American Diabetes Association” was published in the September 2017 issue of Diabetes Care, and online on Aug. 22. The statement updates the ADA’s previous statement on hypertension and diabetes published in 2003.

vitapix/Thinkstock

“Numerous studies have shown that antihypertensive therapy reduces ASCVD [atherosclerotic cardiovascular disease] events, heart failure, and microvascular complications in people with diabetes,” wrote Ian H. de Boer, MD, of the University of Washington, Seattle, and his colleagues.

The statement is a collaboration between nine diabetes experts from the United States, Europe, and Australia whose specialties include endocrinology, nephrology, cardiology, and internal medicine (Diabetes Care. 2017 Sep.;40:1273-84).

The statement recommends that diabetes patients have their blood pressure checked at every routine clinical visit and that those with an elevated blood pressure on a clinical visit (defined as office-based measurements of 140/90 mm Hg and higher) have multiple measurements, including on a separate day to confirm the diagnosis.

In addition, during the initial evaluation, and then periodically, diabetes patients should be assessed for orthostatic hypotension “to individualize blood pressure goals, select the most appropriate antihypertensive agents, and minimize adverse effects of antihypertensive therapy,” according to the recommendations.

For most patients with diabetes and hypertension, the goal should be a blood pressure below 140/90 mm Hg, and even lower targets may be appropriate for patients at high cardiovascular disease risk, the researchers said.

The guidelines include recommendations for managing hypertension and diabetes through lifestyle modifications such as increasing physical activity, achieving and maintaining a healthy weight, and following a healthy diet with minimal sodium intake and an emphasis on fruits, vegetables, and low-fat dairy products.

The guidelines also emphasize the need for caution when treating older adults who are taking multiple medications. “Systolic blood pressure should be the main target of treatment,” for adults aged 65 years and older with diabetes and hypertension, the authors said.

In addition, the guidelines provide direction for clinicians treating pregnant women. “During pregnancy, treatment with ACE inhibitors, ARBs [angiotensin receptor blockers], or spironolactone is contraindicated, as [these medications] may cause fetal damage,” the authors wrote. Pregnant women with preexisting hypertension or with mild gestational hypertension with systolic blood pressure below 160 mm Hg, a diastolic blood pressure below 105 mm Hg, and no sign of end-organ damage need not take antihypertensive medications, they said. For pregnant women who require antihypertensive treatment, the aim should be a systolic blood pressure between 120 mm Hg and 160 mm Hg and a diastolic blood pressure between 80 mm Hg and 105 mm Hg.

The authors concluded that there currently is insufficient evidence to support blood pressure medication for diabetes patients without hypertension.

The recommendations reference several key clinical trials that compared intensive and standard hypertension treatment strategies: the ACCORD BP (Action to Control Cardiovascular Risk in Diabetes – Blood Pressure) trial, the ADVANCE BP (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation – Blood Pressure) trial, the HOT (Hypertension Optimal Treatment) trial, and SPRINT (the Systolic Blood Pressure Intervention Trial).

Lead author Dr. de Boer reported serving as a consultant for Boehringer Ingelheim and Ironwood Pharmaceuticals, and his institution has received research equipment and supplies from Medtronic and Abbott. Study coauthors disclosed relationships with multiple companies including Merck, Abbott, Pfizer, and AstraZeneca.

“If you are 6 months or older in the U.S., there’s a flu vaccine for you,” William Schaffner, MD, of Vanderbilt University, Nashville, said in a press briefing sponsored by the National Foundation for Infectious Diseases.

Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.

Heidi Splete/Frontline Medical News

[email protected]

“If you are 6 months or older in the U.S., there’s a flu vaccine for you,” William Schaffner, MD, of Vanderbilt University, Nashville, said in a press briefing sponsored by the National Foundation for Infectious Diseases.

Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.

Heidi Splete/Frontline Medical News

[email protected]

“If you are 6 months or older in the U.S., there’s a flu vaccine for you,” William Schaffner, MD, of Vanderbilt University, Nashville, said in a press briefing sponsored by the National Foundation for Infectious Diseases.

Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.

Heidi Splete/Frontline Medical News

[email protected]

Fifteen years ago, reported cases of syphilis in the United States were so infrequent that public health officials thought it might join the ranks of malaria, polio, and smallpox as an eradicated disease. That turned out to be wishful thinking.

According to data from the Centers for Disease Control and Prevention, between 2012 and 2015, the overall rates of syphilis in the United States increased by 48%, while the rates of primary and secondary infection among women spiked by 56%. That was a compelling enough rise, but fresh data from the agency indicate that the overall rates of syphilis increased by 17.6% between 2015 and 2016, and by 74% between 2012 and 2016.

Lack of prenatal care

CDC guidelines recommend that all pregnant women undergo routine serologic screening for syphilis during their first prenatal visit. Additional testing at 28 weeks’ gestation and again at delivery is warranted for women who are at increased risk or live in communities with increased prevalence of syphilis infection. That approach may seem sensible, but such prevention measures are ineffective when mothers don’t receive any prenatal care or receive it late, which happens in about half of all CS cases, Dr. Kidd said.

Inconsistent, inadequate, or a total absence of prenatal care is “probably the biggest risk factor for vertical transmission, especially among high-risk populations, where there is an increased background prevalence of syphilis in childbearing women,” said Robert Maupin, MD, professor of clinical obstetrics and gynecology in the section of maternal-fetal medicine at Louisiana State University Health Sciences Center, New Orleans.

Repeat screening

In 2015, a large analysis of women who were commercially-insured or Medicaid-insured found that more than 95% who received prenatal care were screened for syphilis at least once during pregnancy (Obstet Gynecol. 2015;125[5]:1211-6). However, CDC data of CS cases shows that about 15% of their mothers are infected during pregnancy, which would occur after that first screening test.

“That’s where the repeat screening early in the third trimester and at delivery becomes the real issue,” Dr. Kidd said. “For high-risk women, including those who live in the high morbidity areas, they should be screened again later in pregnancy. Many ob.gyns. may not be aware of that recommendation, or may not be aware they’re in an area that does have a high syphilis morbidity, and that the pregnant women who are seeing them may be at increased risk of syphilis.”

Dr. Maupin, who is associate dean of diversity and community engagement at LSU Health Sciences Center, advised clinicians to view CS with the same sense of urgency that existed in previous years with perinatal HIV transmission.

“In the last decade and a half we’ve seen a substantial decline in perinatal HIV transmission because of intensive efforts on the public health side in terms of both screening and use of treatment,” he said. “If we look at this with a similar level of contemporary urgency, it will bear similar fruit over time. Additionally, from a maternal-fetal medicine standpoint, the more effectively we treat and/or control diseases and comorbidities prior to pregnancy, the less likely those things will have an adverse impact on the health and well-being of the newborn.”
 

Steps you can take to curb CS

In its “call to action” on syphilis, the Centers for Disease Control and Prevention cited several practical ways that clinicians can combat the spread of congenital syphilis (CS).

1. Complete a sexual history for your patients. The CDC recommends following this with STD counseling for those at risk and contraception counseling for women at risk of unintended pregnancy.

2. Test all pregnant women for syphilis. This should be done at the first prenatal visit, with repeat screening for pregnant women at high risk and in areas of high prevalence at the beginning of the third trimester and again at delivery.

3. Treat women infected with syphilis immediately. If a woman has syphilis or suspected syphilis, she should be treated with long-acting penicillin G, especially if she is pregnant. CDC also calls for testing and treating the infected woman’s sex partner(s) to avoid reinfection.

4. Confirm syphilis testing at delivery. Before discharging the mother or infant from the hospital, check that the mother has been tested for syphilis at least once during pregnancy or at delivery. All women who deliver a stillborn infant should be tested for syphilis.

5. Report CS cases to the local or state health department within 24 hours.

[email protected]

Fifteen years ago, reported cases of syphilis in the United States were so infrequent that public health officials thought it might join the ranks of malaria, polio, and smallpox as an eradicated disease. That turned out to be wishful thinking.

According to data from the Centers for Disease Control and Prevention, between 2012 and 2015, the overall rates of syphilis in the United States increased by 48%, while the rates of primary and secondary infection among women spiked by 56%. That was a compelling enough rise, but fresh data from the agency indicate that the overall rates of syphilis increased by 17.6% between 2015 and 2016, and by 74% between 2012 and 2016.

Lack of prenatal care

CDC guidelines recommend that all pregnant women undergo routine serologic screening for syphilis during their first prenatal visit. Additional testing at 28 weeks’ gestation and again at delivery is warranted for women who are at increased risk or live in communities with increased prevalence of syphilis infection. That approach may seem sensible, but such prevention measures are ineffective when mothers don’t receive any prenatal care or receive it late, which happens in about half of all CS cases, Dr. Kidd said.

Inconsistent, inadequate, or a total absence of prenatal care is “probably the biggest risk factor for vertical transmission, especially among high-risk populations, where there is an increased background prevalence of syphilis in childbearing women,” said Robert Maupin, MD, professor of clinical obstetrics and gynecology in the section of maternal-fetal medicine at Louisiana State University Health Sciences Center, New Orleans.

Repeat screening

In 2015, a large analysis of women who were commercially-insured or Medicaid-insured found that more than 95% who received prenatal care were screened for syphilis at least once during pregnancy (Obstet Gynecol. 2015;125[5]:1211-6). However, CDC data of CS cases shows that about 15% of their mothers are infected during pregnancy, which would occur after that first screening test.

“That’s where the repeat screening early in the third trimester and at delivery becomes the real issue,” Dr. Kidd said. “For high-risk women, including those who live in the high morbidity areas, they should be screened again later in pregnancy. Many ob.gyns. may not be aware of that recommendation, or may not be aware they’re in an area that does have a high syphilis morbidity, and that the pregnant women who are seeing them may be at increased risk of syphilis.”

Dr. Maupin, who is associate dean of diversity and community engagement at LSU Health Sciences Center, advised clinicians to view CS with the same sense of urgency that existed in previous years with perinatal HIV transmission.

“In the last decade and a half we’ve seen a substantial decline in perinatal HIV transmission because of intensive efforts on the public health side in terms of both screening and use of treatment,” he said. “If we look at this with a similar level of contemporary urgency, it will bear similar fruit over time. Additionally, from a maternal-fetal medicine standpoint, the more effectively we treat and/or control diseases and comorbidities prior to pregnancy, the less likely those things will have an adverse impact on the health and well-being of the newborn.”
 

Steps you can take to curb CS

In its “call to action” on syphilis, the Centers for Disease Control and Prevention cited several practical ways that clinicians can combat the spread of congenital syphilis (CS).

1. Complete a sexual history for your patients. The CDC recommends following this with STD counseling for those at risk and contraception counseling for women at risk of unintended pregnancy.

2. Test all pregnant women for syphilis. This should be done at the first prenatal visit, with repeat screening for pregnant women at high risk and in areas of high prevalence at the beginning of the third trimester and again at delivery.

3. Treat women infected with syphilis immediately. If a woman has syphilis or suspected syphilis, she should be treated with long-acting penicillin G, especially if she is pregnant. CDC also calls for testing and treating the infected woman’s sex partner(s) to avoid reinfection.

4. Confirm syphilis testing at delivery. Before discharging the mother or infant from the hospital, check that the mother has been tested for syphilis at least once during pregnancy or at delivery. All women who deliver a stillborn infant should be tested for syphilis.

5. Report CS cases to the local or state health department within 24 hours.

[email protected]

Fifteen years ago, reported cases of syphilis in the United States were so infrequent that public health officials thought it might join the ranks of malaria, polio, and smallpox as an eradicated disease. That turned out to be wishful thinking.

According to data from the Centers for Disease Control and Prevention, between 2012 and 2015, the overall rates of syphilis in the United States increased by 48%, while the rates of primary and secondary infection among women spiked by 56%. That was a compelling enough rise, but fresh data from the agency indicate that the overall rates of syphilis increased by 17.6% between 2015 and 2016, and by 74% between 2012 and 2016.

Lack of prenatal care

CDC guidelines recommend that all pregnant women undergo routine serologic screening for syphilis during their first prenatal visit. Additional testing at 28 weeks’ gestation and again at delivery is warranted for women who are at increased risk or live in communities with increased prevalence of syphilis infection. That approach may seem sensible, but such prevention measures are ineffective when mothers don’t receive any prenatal care or receive it late, which happens in about half of all CS cases, Dr. Kidd said.

Inconsistent, inadequate, or a total absence of prenatal care is “probably the biggest risk factor for vertical transmission, especially among high-risk populations, where there is an increased background prevalence of syphilis in childbearing women,” said Robert Maupin, MD, professor of clinical obstetrics and gynecology in the section of maternal-fetal medicine at Louisiana State University Health Sciences Center, New Orleans.

Repeat screening

In 2015, a large analysis of women who were commercially-insured or Medicaid-insured found that more than 95% who received prenatal care were screened for syphilis at least once during pregnancy (Obstet Gynecol. 2015;125[5]:1211-6). However, CDC data of CS cases shows that about 15% of their mothers are infected during pregnancy, which would occur after that first screening test.

“That’s where the repeat screening early in the third trimester and at delivery becomes the real issue,” Dr. Kidd said. “For high-risk women, including those who live in the high morbidity areas, they should be screened again later in pregnancy. Many ob.gyns. may not be aware of that recommendation, or may not be aware they’re in an area that does have a high syphilis morbidity, and that the pregnant women who are seeing them may be at increased risk of syphilis.”

Dr. Maupin, who is associate dean of diversity and community engagement at LSU Health Sciences Center, advised clinicians to view CS with the same sense of urgency that existed in previous years with perinatal HIV transmission.

“In the last decade and a half we’ve seen a substantial decline in perinatal HIV transmission because of intensive efforts on the public health side in terms of both screening and use of treatment,” he said. “If we look at this with a similar level of contemporary urgency, it will bear similar fruit over time. Additionally, from a maternal-fetal medicine standpoint, the more effectively we treat and/or control diseases and comorbidities prior to pregnancy, the less likely those things will have an adverse impact on the health and well-being of the newborn.”
 

Steps you can take to curb CS

In its “call to action” on syphilis, the Centers for Disease Control and Prevention cited several practical ways that clinicians can combat the spread of congenital syphilis (CS).

1. Complete a sexual history for your patients. The CDC recommends following this with STD counseling for those at risk and contraception counseling for women at risk of unintended pregnancy.

2. Test all pregnant women for syphilis. This should be done at the first prenatal visit, with repeat screening for pregnant women at high risk and in areas of high prevalence at the beginning of the third trimester and again at delivery.

3. Treat women infected with syphilis immediately. If a woman has syphilis or suspected syphilis, she should be treated with long-acting penicillin G, especially if she is pregnant. CDC also calls for testing and treating the infected woman’s sex partner(s) to avoid reinfection.

4. Confirm syphilis testing at delivery. Before discharging the mother or infant from the hospital, check that the mother has been tested for syphilis at least once during pregnancy or at delivery. All women who deliver a stillborn infant should be tested for syphilis.

5. Report CS cases to the local or state health department within 24 hours.

[email protected]

In 2015 more than 30,000 deaths from opioid overdose were reported (FIGURE).¹ More than 50% of the deaths were due to prescription opioids. The opioid crisis is a public health emergency and clinicians are diligently working to reduce both the number of opioid prescriptions and the doses prescribed per prescription.

In obstetrics, there is growing concern that narcotics used for the treatment of pain in women who are breastfeeding may increase the risk of adverse effects in newborns, including excessive sedation and respiratory depression. The American Academy of Pediatrics (AAP), the US Food and Drug Administration (FDA) and the American College of Obstetricians and Gynecologists (ACOG) recommend against the use of codeine and tramadol in women who are breastfeeding because their newborns may have adverse reactions, including excessive sleepiness, difficulty breathing, and potentially fatal breathing problems.^2–4 In addition, there is growing concern that the use of oxycodone and hydrocodone should also be limited in women who are breastfeeding. In this article, I discuss the rationale for these recommendations.

Related article:
Landmark women’s health care remains law of the land

Codeine

Codeine is metabolized to morphine by CYP2D6 and CYP2D7. Both codeine and morphine are excreted into breast milk. Some women are ultrarapid metabolizers of codeine because of high levels of CYP2D6, resulting in higher concentrations of morphine in their breast milk and their breast fed newborn.^2,5 In many women who are ultra-rapid metabolizers of codeine, CYP2D6 gene duplication or multiplication is the cause of the increased enzyme activity.⁶ Genotyping can identify some women who are ultrarapid metabolizers, but it is not currently utilized widely in clinical practice.

In the United States approximately 5% of women express high levels of CYP2D6 and are ultra-rapid metabolizers of codeine.⁴ In Ethiopia as many as 29% of women are ultrarapid metabolizers.⁷ Newborn central nervous system (CNS) depression is the most common adverse effect of fetal ingestion of excessive codeine and mor-phine from breast milk and may present as sedation, apnea, bradycardia, or cyanosis.⁸ Multiple newborn fatalities have been re-ported in the literature when lactating mothers who were ultrarapid metabolizers took co-deine. The FDA and ACOG recommend against the use of codeine in lactating women.

Hydrocodone

Hydrocodone, a hydrogenated ketone derivative of codeine, is metabolized by CYP2D6 to hydromorphone. Both hydrocodone and hydromorphone are present in breast milk. In lactating mothers taking hydrocodone, up to 9% of the dose may be ingested by the breastfeeding newborn.⁹ There is concern that hydrocodone use by women who are breastfeeding and are ultrarapid metabolizers may cause increased fetal consumption of hydromorphone resulting in adverse outcomes in the newborn. The AAP cautions against the use of hydrocodone.²

Oxycodone

Oxycodone is metabolized by CYP2D6 to oxymorphone and is concentrated into breast milk.¹⁰ Oxymorphone is more than 10 times more potent than oxycodone. In one study of lactating women taking oxycodone, codeine, or acetaminophen, the rates of neonate CNS depression were 20%, 17%, and 0.5%, respectively.¹¹ The authors concluded that for mothers who are breastfeeding oxycodone was no safer than codeine because both medications were associated with a high rate of depression in the neonate. Newborns who develop CNS depression from exposure to oxycodone in breast milk will respond to naloxone treatment.¹² The AAP recommends against prescribing oxycodone for women who are breastfeeding their infants.²

In a recent communication, the Society for Obstetric Anesthesia and Perinatology (SOAP) observed that in the United States, following cesarean delivery the majority of women receive oxycodone or hydrocodone.¹³ SOAP disagreed with the AAP recommendation against the use of oxycodone or hydrocodone in breastfeeding women. SOAP noted that all narcotics can produce adverse effects in newborns of breastfeeding women and that there are no good data that the prescription of oxycodone or hydrocodone is more risky than morphine or hydromorphone. However, based on their assessment of risk and benefit, pediatricians prioritize the use of acetaminophen and morphine and seldom use oxycodone or hydrocodone to treat moderate to severe pain in babies and children.

Tramadol

Tramadol is metabolized by CYP2D6 to O-desmethyltramadol. Both tramadol and O-desmethyltramadol are excreted into breast milk. In ultrarapid metabolizers, a greater concentration of O-desmethyltramadol is excreted into breast milk. The FDA reported that they identified no serious neonatal adverse events in the literature due to the use of tramadol by women who are breastfeeding. However, given that tramadol and its CYP2D6 metabolite enter breast milk and the potential for life-threatening respiratory de-pression in the infant, the FDA included tramadol in its warning about codeine.³

Codeine, hydrocodone, oxycodone, and tramadol are all metabolized to more potent metabolites by the CYP2D6 enzyme. Individuals with low CYP2D6 activity, representing about 5% of the US population, cannot fully activate these narcotics. Hence they may not get adequate pain relief when treated with codeine, oxycodone, hydrocodone, or tramadol. Given their resistance to these medications they may first be placed on a higher dose of the narcotic and then switched from a high ineffective dose of one of the agents activated by CYP2D6 to a high dose of morphine or hydromorphone. This can be dangerous because they may then receive an excessive dose of narcotic and develop respiratory depression.¹⁴

Read about how other pain medications affect breast milk.

Aspirin

There are very little high quality data about the use of aspirin in women breastfeeding and the effect on the neonate. If a mother takes aspirin, the drug will enter breast milk. It is estimated that the nursing baby receives about 4% to 8% of the mother’s dose. The World Health Organization recommends that aspirin is compatible with breastfeeding in occasional small doses, but repeated administration of aspirin in normal doses should be avoided in women who are breastfeeding. If chronic or high-dose aspirin therapy is recommended, the infant should be monitored for side effects including metabolic acidosis¹⁵ and coagulation disorders.¹⁶ The National Reye’s Syndrome Foundation recommends against the use of aspirin in women who are breastfeeding because of the theoretical risk of triggering Reye syndrome.¹⁷ Acetaminophen and ibuprofen are recommended by the WHO for chronic treatment of pain during breastfeeding.¹⁶

Acetaminophen and ibuprofen

For the medication treatment of pain in women who are breastfeeding, the WHO recommends the use of acetaminophen and ibuprofen.¹⁶ Acetaminophen is transferred from the maternal circulation into breast milk, but it is estimated that the dose to the nursing neonate is <0.3% of the maternal dose.¹⁸ In mothers taking ibuprofen 1600 mg daily, the concentration of ibuprofen in breast milk was below the level of laboratory detection (<1 mg/L).¹⁹ Ibuprofen treatment is thought to be safe for women who are breastfeeding because of its short half-life (2 hours), low excretion into milk, and few reported adverse effects in infants.

Morphine

Morphine is not metabolized by CYP2D6 and is excreted into breast milk. Many experts believe that women who are breastfeeding may take standard doses of oral morphine with few adverse effects in the newborn.^20,21 For the treatment of moderate to severe pain in opioid-naive adults, morphine doses in the range of 10 mg orally every 4 hours up to 30 mg orally every 4 hours are prescribed. When using a solution of morphine, standard doses are 10 mg to 20 mg every 4 hours, as needed to treat pain. When using morphine tablets, standard doses are 15 mg to 30 mg every 4 hours. The WHO states that occasional doses of morphine are usually safe for women breastfeeding their newborn.¹⁶ The AAP recommends the use of morphine and hydromorphone when narcotic agents are needed to treat pain in breastfeeding women.²

Hydromorphone

Hydromorphone, a hydrogenated ketone derivative of morphine, is not metabolized by CYP2D6 and is excreted into breast milk. There are limited data on the safety of hydromorphone during breastfeeding. Breast milk concentrations of hydromorphone are low, and an occasional dose is likely associated with few adverse effects in the breastfeeding newborn.²² For the treatment of moderate to severe pain in opioid-naive adults, hydromorphone doses in the range of 2 mg orally every 4 hours up to 4 mg orally every 4 hours are prescribed. Like all narcotics, hydromorphone can result in central nervous system depression. If a mother ingests sufficient quantities of hydromorphone, respiratory depression in the breastfeeding newborn can occur. In one case report, a nursing mother was taking hydromorphone 4 mg every 4 hours for pain following a cesarean delivery. On day 6 following birth, her newborn was lethargic and she brought the infant to an emergency room. In the emergency room the infant became apneic and was successfully treated with naloxone, suggesting anarcotic overdose due to the presence of hydromorphone in breast milk.²³ Hydromorphone should only be used at the lowest effective dose and for the shortest time possible.

Related article:
Should coffee consumption be added as an adjunct to the postoperative care of gynecologic oncology patients?

The bottom line

Pediatricians seldom prescribe codeine, oxycodone, hydrocodone, or tramadol for the treatment of pain in newborns or children. Pediatricians generally use acetaminophen and morphine for the treatment of pain in newborns. Although data from large, high quality clinical trials are not available, expert opinion recommends that acetaminophen and ibuprofen should be prescribed as first-line medications for the treatment of pain in women who are breastfeeding. Use of narcotics that are metabolized by CYP2D6 should be minimized or avoided in women who are breastfeeding. If narcotic medication is necessary, the lowest effective dose of morphine or hy-dromorphone should be prescribed for the shortest time possible. If morphine is prescribed to wo-men who are breastfeeding, they should be advised to observe their baby for signs of narcotic excess, including drowsiness, poor nursing, slow breathing, or low heart rate.

The goal of reducing morbidity and mortality from opioid use is a top public health priority. Obstetrician-gynecologists can contribute through the optimal use of opioid analgesics. Reducing the number of opioid prescriptions and the quantity of medication prescribed per prescription is an important first step in our effort to reduce opioid-related deaths.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In 2015 more than 30,000 deaths from opioid overdose were reported (FIGURE).¹ More than 50% of the deaths were due to prescription opioids. The opioid crisis is a public health emergency and clinicians are diligently working to reduce both the number of opioid prescriptions and the doses prescribed per prescription.

In obstetrics, there is growing concern that narcotics used for the treatment of pain in women who are breastfeeding may increase the risk of adverse effects in newborns, including excessive sedation and respiratory depression. The American Academy of Pediatrics (AAP), the US Food and Drug Administration (FDA) and the American College of Obstetricians and Gynecologists (ACOG) recommend against the use of codeine and tramadol in women who are breastfeeding because their newborns may have adverse reactions, including excessive sleepiness, difficulty breathing, and potentially fatal breathing problems.^2–4 In addition, there is growing concern that the use of oxycodone and hydrocodone should also be limited in women who are breastfeeding. In this article, I discuss the rationale for these recommendations.

Related article:
Landmark women’s health care remains law of the land

Codeine

Codeine is metabolized to morphine by CYP2D6 and CYP2D7. Both codeine and morphine are excreted into breast milk. Some women are ultrarapid metabolizers of codeine because of high levels of CYP2D6, resulting in higher concentrations of morphine in their breast milk and their breast fed newborn.^2,5 In many women who are ultra-rapid metabolizers of codeine, CYP2D6 gene duplication or multiplication is the cause of the increased enzyme activity.⁶ Genotyping can identify some women who are ultrarapid metabolizers, but it is not currently utilized widely in clinical practice.

In the United States approximately 5% of women express high levels of CYP2D6 and are ultra-rapid metabolizers of codeine.⁴ In Ethiopia as many as 29% of women are ultrarapid metabolizers.⁷ Newborn central nervous system (CNS) depression is the most common adverse effect of fetal ingestion of excessive codeine and mor-phine from breast milk and may present as sedation, apnea, bradycardia, or cyanosis.⁸ Multiple newborn fatalities have been re-ported in the literature when lactating mothers who were ultrarapid metabolizers took co-deine. The FDA and ACOG recommend against the use of codeine in lactating women.

Hydrocodone

Hydrocodone, a hydrogenated ketone derivative of codeine, is metabolized by CYP2D6 to hydromorphone. Both hydrocodone and hydromorphone are present in breast milk. In lactating mothers taking hydrocodone, up to 9% of the dose may be ingested by the breastfeeding newborn.⁹ There is concern that hydrocodone use by women who are breastfeeding and are ultrarapid metabolizers may cause increased fetal consumption of hydromorphone resulting in adverse outcomes in the newborn. The AAP cautions against the use of hydrocodone.²

Oxycodone

Oxycodone is metabolized by CYP2D6 to oxymorphone and is concentrated into breast milk.¹⁰ Oxymorphone is more than 10 times more potent than oxycodone. In one study of lactating women taking oxycodone, codeine, or acetaminophen, the rates of neonate CNS depression were 20%, 17%, and 0.5%, respectively.¹¹ The authors concluded that for mothers who are breastfeeding oxycodone was no safer than codeine because both medications were associated with a high rate of depression in the neonate. Newborns who develop CNS depression from exposure to oxycodone in breast milk will respond to naloxone treatment.¹² The AAP recommends against prescribing oxycodone for women who are breastfeeding their infants.²

In a recent communication, the Society for Obstetric Anesthesia and Perinatology (SOAP) observed that in the United States, following cesarean delivery the majority of women receive oxycodone or hydrocodone.¹³ SOAP disagreed with the AAP recommendation against the use of oxycodone or hydrocodone in breastfeeding women. SOAP noted that all narcotics can produce adverse effects in newborns of breastfeeding women and that there are no good data that the prescription of oxycodone or hydrocodone is more risky than morphine or hydromorphone. However, based on their assessment of risk and benefit, pediatricians prioritize the use of acetaminophen and morphine and seldom use oxycodone or hydrocodone to treat moderate to severe pain in babies and children.

Tramadol

Tramadol is metabolized by CYP2D6 to O-desmethyltramadol. Both tramadol and O-desmethyltramadol are excreted into breast milk. In ultrarapid metabolizers, a greater concentration of O-desmethyltramadol is excreted into breast milk. The FDA reported that they identified no serious neonatal adverse events in the literature due to the use of tramadol by women who are breastfeeding. However, given that tramadol and its CYP2D6 metabolite enter breast milk and the potential for life-threatening respiratory de-pression in the infant, the FDA included tramadol in its warning about codeine.³

Codeine, hydrocodone, oxycodone, and tramadol are all metabolized to more potent metabolites by the CYP2D6 enzyme. Individuals with low CYP2D6 activity, representing about 5% of the US population, cannot fully activate these narcotics. Hence they may not get adequate pain relief when treated with codeine, oxycodone, hydrocodone, or tramadol. Given their resistance to these medications they may first be placed on a higher dose of the narcotic and then switched from a high ineffective dose of one of the agents activated by CYP2D6 to a high dose of morphine or hydromorphone. This can be dangerous because they may then receive an excessive dose of narcotic and develop respiratory depression.¹⁴

Read about how other pain medications affect breast milk.

Aspirin

There are very little high quality data about the use of aspirin in women breastfeeding and the effect on the neonate. If a mother takes aspirin, the drug will enter breast milk. It is estimated that the nursing baby receives about 4% to 8% of the mother’s dose. The World Health Organization recommends that aspirin is compatible with breastfeeding in occasional small doses, but repeated administration of aspirin in normal doses should be avoided in women who are breastfeeding. If chronic or high-dose aspirin therapy is recommended, the infant should be monitored for side effects including metabolic acidosis¹⁵ and coagulation disorders.¹⁶ The National Reye’s Syndrome Foundation recommends against the use of aspirin in women who are breastfeeding because of the theoretical risk of triggering Reye syndrome.¹⁷ Acetaminophen and ibuprofen are recommended by the WHO for chronic treatment of pain during breastfeeding.¹⁶

Acetaminophen and ibuprofen

For the medication treatment of pain in women who are breastfeeding, the WHO recommends the use of acetaminophen and ibuprofen.¹⁶ Acetaminophen is transferred from the maternal circulation into breast milk, but it is estimated that the dose to the nursing neonate is <0.3% of the maternal dose.¹⁸ In mothers taking ibuprofen 1600 mg daily, the concentration of ibuprofen in breast milk was below the level of laboratory detection (<1 mg/L).¹⁹ Ibuprofen treatment is thought to be safe for women who are breastfeeding because of its short half-life (2 hours), low excretion into milk, and few reported adverse effects in infants.

Morphine

Morphine is not metabolized by CYP2D6 and is excreted into breast milk. Many experts believe that women who are breastfeeding may take standard doses of oral morphine with few adverse effects in the newborn.^20,21 For the treatment of moderate to severe pain in opioid-naive adults, morphine doses in the range of 10 mg orally every 4 hours up to 30 mg orally every 4 hours are prescribed. When using a solution of morphine, standard doses are 10 mg to 20 mg every 4 hours, as needed to treat pain. When using morphine tablets, standard doses are 15 mg to 30 mg every 4 hours. The WHO states that occasional doses of morphine are usually safe for women breastfeeding their newborn.¹⁶ The AAP recommends the use of morphine and hydromorphone when narcotic agents are needed to treat pain in breastfeeding women.²

Hydromorphone

Hydromorphone, a hydrogenated ketone derivative of morphine, is not metabolized by CYP2D6 and is excreted into breast milk. There are limited data on the safety of hydromorphone during breastfeeding. Breast milk concentrations of hydromorphone are low, and an occasional dose is likely associated with few adverse effects in the breastfeeding newborn.²² For the treatment of moderate to severe pain in opioid-naive adults, hydromorphone doses in the range of 2 mg orally every 4 hours up to 4 mg orally every 4 hours are prescribed. Like all narcotics, hydromorphone can result in central nervous system depression. If a mother ingests sufficient quantities of hydromorphone, respiratory depression in the breastfeeding newborn can occur. In one case report, a nursing mother was taking hydromorphone 4 mg every 4 hours for pain following a cesarean delivery. On day 6 following birth, her newborn was lethargic and she brought the infant to an emergency room. In the emergency room the infant became apneic and was successfully treated with naloxone, suggesting anarcotic overdose due to the presence of hydromorphone in breast milk.²³ Hydromorphone should only be used at the lowest effective dose and for the shortest time possible.

Related article:
Should coffee consumption be added as an adjunct to the postoperative care of gynecologic oncology patients?

The bottom line

Pediatricians seldom prescribe codeine, oxycodone, hydrocodone, or tramadol for the treatment of pain in newborns or children. Pediatricians generally use acetaminophen and morphine for the treatment of pain in newborns. Although data from large, high quality clinical trials are not available, expert opinion recommends that acetaminophen and ibuprofen should be prescribed as first-line medications for the treatment of pain in women who are breastfeeding. Use of narcotics that are metabolized by CYP2D6 should be minimized or avoided in women who are breastfeeding. If narcotic medication is necessary, the lowest effective dose of morphine or hy-dromorphone should be prescribed for the shortest time possible. If morphine is prescribed to wo-men who are breastfeeding, they should be advised to observe their baby for signs of narcotic excess, including drowsiness, poor nursing, slow breathing, or low heart rate.

The goal of reducing morbidity and mortality from opioid use is a top public health priority. Obstetrician-gynecologists can contribute through the optimal use of opioid analgesics. Reducing the number of opioid prescriptions and the quantity of medication prescribed per prescription is an important first step in our effort to reduce opioid-related deaths.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

In 2015 more than 30,000 deaths from opioid overdose were reported (FIGURE).¹ More than 50% of the deaths were due to prescription opioids. The opioid crisis is a public health emergency and clinicians are diligently working to reduce both the number of opioid prescriptions and the doses prescribed per prescription.

In obstetrics, there is growing concern that narcotics used for the treatment of pain in women who are breastfeeding may increase the risk of adverse effects in newborns, including excessive sedation and respiratory depression. The American Academy of Pediatrics (AAP), the US Food and Drug Administration (FDA) and the American College of Obstetricians and Gynecologists (ACOG) recommend against the use of codeine and tramadol in women who are breastfeeding because their newborns may have adverse reactions, including excessive sleepiness, difficulty breathing, and potentially fatal breathing problems.^2–4 In addition, there is growing concern that the use of oxycodone and hydrocodone should also be limited in women who are breastfeeding. In this article, I discuss the rationale for these recommendations.

Related article:
Landmark women’s health care remains law of the land

Codeine

Codeine is metabolized to morphine by CYP2D6 and CYP2D7. Both codeine and morphine are excreted into breast milk. Some women are ultrarapid metabolizers of codeine because of high levels of CYP2D6, resulting in higher concentrations of morphine in their breast milk and their breast fed newborn.^2,5 In many women who are ultra-rapid metabolizers of codeine, CYP2D6 gene duplication or multiplication is the cause of the increased enzyme activity.⁶ Genotyping can identify some women who are ultrarapid metabolizers, but it is not currently utilized widely in clinical practice.

In the United States approximately 5% of women express high levels of CYP2D6 and are ultra-rapid metabolizers of codeine.⁴ In Ethiopia as many as 29% of women are ultrarapid metabolizers.⁷ Newborn central nervous system (CNS) depression is the most common adverse effect of fetal ingestion of excessive codeine and mor-phine from breast milk and may present as sedation, apnea, bradycardia, or cyanosis.⁸ Multiple newborn fatalities have been re-ported in the literature when lactating mothers who were ultrarapid metabolizers took co-deine. The FDA and ACOG recommend against the use of codeine in lactating women.

Hydrocodone

Hydrocodone, a hydrogenated ketone derivative of codeine, is metabolized by CYP2D6 to hydromorphone. Both hydrocodone and hydromorphone are present in breast milk. In lactating mothers taking hydrocodone, up to 9% of the dose may be ingested by the breastfeeding newborn.⁹ There is concern that hydrocodone use by women who are breastfeeding and are ultrarapid metabolizers may cause increased fetal consumption of hydromorphone resulting in adverse outcomes in the newborn. The AAP cautions against the use of hydrocodone.²

Oxycodone

Oxycodone is metabolized by CYP2D6 to oxymorphone and is concentrated into breast milk.¹⁰ Oxymorphone is more than 10 times more potent than oxycodone. In one study of lactating women taking oxycodone, codeine, or acetaminophen, the rates of neonate CNS depression were 20%, 17%, and 0.5%, respectively.¹¹ The authors concluded that for mothers who are breastfeeding oxycodone was no safer than codeine because both medications were associated with a high rate of depression in the neonate. Newborns who develop CNS depression from exposure to oxycodone in breast milk will respond to naloxone treatment.¹² The AAP recommends against prescribing oxycodone for women who are breastfeeding their infants.²

In a recent communication, the Society for Obstetric Anesthesia and Perinatology (SOAP) observed that in the United States, following cesarean delivery the majority of women receive oxycodone or hydrocodone.¹³ SOAP disagreed with the AAP recommendation against the use of oxycodone or hydrocodone in breastfeeding women. SOAP noted that all narcotics can produce adverse effects in newborns of breastfeeding women and that there are no good data that the prescription of oxycodone or hydrocodone is more risky than morphine or hydromorphone. However, based on their assessment of risk and benefit, pediatricians prioritize the use of acetaminophen and morphine and seldom use oxycodone or hydrocodone to treat moderate to severe pain in babies and children.

Tramadol

Tramadol is metabolized by CYP2D6 to O-desmethyltramadol. Both tramadol and O-desmethyltramadol are excreted into breast milk. In ultrarapid metabolizers, a greater concentration of O-desmethyltramadol is excreted into breast milk. The FDA reported that they identified no serious neonatal adverse events in the literature due to the use of tramadol by women who are breastfeeding. However, given that tramadol and its CYP2D6 metabolite enter breast milk and the potential for life-threatening respiratory de-pression in the infant, the FDA included tramadol in its warning about codeine.³

Codeine, hydrocodone, oxycodone, and tramadol are all metabolized to more potent metabolites by the CYP2D6 enzyme. Individuals with low CYP2D6 activity, representing about 5% of the US population, cannot fully activate these narcotics. Hence they may not get adequate pain relief when treated with codeine, oxycodone, hydrocodone, or tramadol. Given their resistance to these medications they may first be placed on a higher dose of the narcotic and then switched from a high ineffective dose of one of the agents activated by CYP2D6 to a high dose of morphine or hydromorphone. This can be dangerous because they may then receive an excessive dose of narcotic and develop respiratory depression.¹⁴

Read about how other pain medications affect breast milk.

Aspirin

There are very little high quality data about the use of aspirin in women breastfeeding and the effect on the neonate. If a mother takes aspirin, the drug will enter breast milk. It is estimated that the nursing baby receives about 4% to 8% of the mother’s dose. The World Health Organization recommends that aspirin is compatible with breastfeeding in occasional small doses, but repeated administration of aspirin in normal doses should be avoided in women who are breastfeeding. If chronic or high-dose aspirin therapy is recommended, the infant should be monitored for side effects including metabolic acidosis¹⁵ and coagulation disorders.¹⁶ The National Reye’s Syndrome Foundation recommends against the use of aspirin in women who are breastfeeding because of the theoretical risk of triggering Reye syndrome.¹⁷ Acetaminophen and ibuprofen are recommended by the WHO for chronic treatment of pain during breastfeeding.¹⁶

Acetaminophen and ibuprofen

For the medication treatment of pain in women who are breastfeeding, the WHO recommends the use of acetaminophen and ibuprofen.¹⁶ Acetaminophen is transferred from the maternal circulation into breast milk, but it is estimated that the dose to the nursing neonate is <0.3% of the maternal dose.¹⁸ In mothers taking ibuprofen 1600 mg daily, the concentration of ibuprofen in breast milk was below the level of laboratory detection (<1 mg/L).¹⁹ Ibuprofen treatment is thought to be safe for women who are breastfeeding because of its short half-life (2 hours), low excretion into milk, and few reported adverse effects in infants.

Morphine

Morphine is not metabolized by CYP2D6 and is excreted into breast milk. Many experts believe that women who are breastfeeding may take standard doses of oral morphine with few adverse effects in the newborn.^20,21 For the treatment of moderate to severe pain in opioid-naive adults, morphine doses in the range of 10 mg orally every 4 hours up to 30 mg orally every 4 hours are prescribed. When using a solution of morphine, standard doses are 10 mg to 20 mg every 4 hours, as needed to treat pain. When using morphine tablets, standard doses are 15 mg to 30 mg every 4 hours. The WHO states that occasional doses of morphine are usually safe for women breastfeeding their newborn.¹⁶ The AAP recommends the use of morphine and hydromorphone when narcotic agents are needed to treat pain in breastfeeding women.²

Hydromorphone

Hydromorphone, a hydrogenated ketone derivative of morphine, is not metabolized by CYP2D6 and is excreted into breast milk. There are limited data on the safety of hydromorphone during breastfeeding. Breast milk concentrations of hydromorphone are low, and an occasional dose is likely associated with few adverse effects in the breastfeeding newborn.²² For the treatment of moderate to severe pain in opioid-naive adults, hydromorphone doses in the range of 2 mg orally every 4 hours up to 4 mg orally every 4 hours are prescribed. Like all narcotics, hydromorphone can result in central nervous system depression. If a mother ingests sufficient quantities of hydromorphone, respiratory depression in the breastfeeding newborn can occur. In one case report, a nursing mother was taking hydromorphone 4 mg every 4 hours for pain following a cesarean delivery. On day 6 following birth, her newborn was lethargic and she brought the infant to an emergency room. In the emergency room the infant became apneic and was successfully treated with naloxone, suggesting anarcotic overdose due to the presence of hydromorphone in breast milk.²³ Hydromorphone should only be used at the lowest effective dose and for the shortest time possible.

Related article:
Should coffee consumption be added as an adjunct to the postoperative care of gynecologic oncology patients?

The bottom line

Pediatricians seldom prescribe codeine, oxycodone, hydrocodone, or tramadol for the treatment of pain in newborns or children. Pediatricians generally use acetaminophen and morphine for the treatment of pain in newborns. Although data from large, high quality clinical trials are not available, expert opinion recommends that acetaminophen and ibuprofen should be prescribed as first-line medications for the treatment of pain in women who are breastfeeding. Use of narcotics that are metabolized by CYP2D6 should be minimized or avoided in women who are breastfeeding. If narcotic medication is necessary, the lowest effective dose of morphine or hy-dromorphone should be prescribed for the shortest time possible. If morphine is prescribed to wo-men who are breastfeeding, they should be advised to observe their baby for signs of narcotic excess, including drowsiness, poor nursing, slow breathing, or low heart rate.

The goal of reducing morbidity and mortality from opioid use is a top public health priority. Obstetrician-gynecologists can contribute through the optimal use of opioid analgesics. Reducing the number of opioid prescriptions and the quantity of medication prescribed per prescription is an important first step in our effort to reduce opioid-related deaths.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Photo: Shutterstock

Many hospitals across the country have received designation as “Baby Friendly”; many other hospitals are in the process of seeking this designation. In order to be Baby Friendly, a hospital or birth center must prove they have implemented a set of 10 rules to encourage breastfeeding. As Baby Friendly USA puts it in their byline, it has become the gold standard of care.

Importantly, Baby Friendly fails to recognize that there is another equally crucial participant in any childbirth experience—the woman. Although childbirth is natural and usually healthy, it is not easy. Women commonly lose up to 1 L of blood during childbirth.¹ Labor can take 18 to 24 hours for a first-timer and about 12 to 18 hours for an encore performance, often disrupting at least1 entire night of sleep. The minimally invasive cesarean delivery continues to elude us, and women undergoing cesarean delivery must contend with a sizable incision and the additional pain and associated recovery.

Hospitals adopting the Baby Friendly rules must not allow formula, must prohibit pacifier use, and must go to great lengths to encourage rooming-in. Rooming-in means that the baby shares the same room as the new mother around-the-clock, which is reported to help the new mother distinguish sounds that indicate “feed me” from those that indicate a cool breeze. Rooming-in has been shown to be associated with a modest increase in breastfeeding²; however, women who are committed to breastfeeding likely room-in more often than women less committed to breastfeeding. Whether or not forcing the woman who is less committed to breastfeeding or the woman highly committed to breastfeeding who just wants a good night’s rest to room-in with her baby has a meaningful impact on breastfeeding remains unknown.

Are we violating ethics rules?

When hospitals adopt the Baby Friendly rules—policies that limit women’s choices for themselves and for their baby—we violate medical ethics principles regarding respect for autonomy, beneficence, and truthfulness. For instance, women are told that if they breastfeed their babies will be smarter, healthier, and have stronger emotional bonds. However, when research studies control for factors such as mothers’ education level or the amount of time spent talking to the baby, the effect of breastfeeding on intelligence “washes out.”³ Babies who are formula-fed but cuddled experience the same degree of bonding with their mothers as breast-fed babies.^4,5

Although breast is best, the reported benefits that underlie Baby Friendly are overblown and oversold. When we explain to a woman why her newborn cannot spend a few hours in the nursery or why we cannot allow a pacifier, we are denying her the right to parent and make choices for herself and her baby, not acting in the best interest of the woman. We are in fact misrepresenting the truth. We are also acting paternalistic, propagating the long tradition of telling women that we know better about their reproductive health and choices.

Related article:
Women’s Preventive Services Initiative Guidelines provide consensus for practicing ObGyns

Breastfeeding still not fully accepted outside the hospital

The Baby Friendly rules restrict autonomy and prod women to breastfeed for the few days that they remain in the hospital postpartum. However, these women go home to societal and institutional systems that are deeply unsupportive of breastfeeding. In addition to being the birthplace for 98% of babies born in the United States, the health care industry is the single largest employer of US women.^6,7 There are 5 academic hospitals in the Boston area. After contacting the human resources department at each, I found that only 1 has a policy for their breastfeeding employees.

Women should not be forced to choose between breastfeeding and working, between taking a longer maternity leave (often unpaid and professionally detrimental) and shelving the breast pump. What we invest in reveals our values. When we require women to room-in without respecting their choices or needs, and when workplaces fail to provide reasonable flexibility and private space for breast-pumping employees, our values as a society are revealed.

Women and men, hospital users and hospital employees, need to insist that the principles of autonomy, respect for persons, truthfulness, and justice guide breastfeeding policy both within our hospitals and within our workplaces. We need to respect women and the choices that they make for themselves and their families. We need to allow women to decide to recover from their delivery without their baby constantly in arms’ reach. We need to ensure that our counseling and our policies are rooted in sound science and not influenced by passionate but biased perspectives.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Photo: Shutterstock

Many hospitals across the country have received designation as “Baby Friendly”; many other hospitals are in the process of seeking this designation. In order to be Baby Friendly, a hospital or birth center must prove they have implemented a set of 10 rules to encourage breastfeeding. As Baby Friendly USA puts it in their byline, it has become the gold standard of care.

Importantly, Baby Friendly fails to recognize that there is another equally crucial participant in any childbirth experience—the woman. Although childbirth is natural and usually healthy, it is not easy. Women commonly lose up to 1 L of blood during childbirth.¹ Labor can take 18 to 24 hours for a first-timer and about 12 to 18 hours for an encore performance, often disrupting at least1 entire night of sleep. The minimally invasive cesarean delivery continues to elude us, and women undergoing cesarean delivery must contend with a sizable incision and the additional pain and associated recovery.

Hospitals adopting the Baby Friendly rules must not allow formula, must prohibit pacifier use, and must go to great lengths to encourage rooming-in. Rooming-in means that the baby shares the same room as the new mother around-the-clock, which is reported to help the new mother distinguish sounds that indicate “feed me” from those that indicate a cool breeze. Rooming-in has been shown to be associated with a modest increase in breastfeeding²; however, women who are committed to breastfeeding likely room-in more often than women less committed to breastfeeding. Whether or not forcing the woman who is less committed to breastfeeding or the woman highly committed to breastfeeding who just wants a good night’s rest to room-in with her baby has a meaningful impact on breastfeeding remains unknown.

Are we violating ethics rules?

When hospitals adopt the Baby Friendly rules—policies that limit women’s choices for themselves and for their baby—we violate medical ethics principles regarding respect for autonomy, beneficence, and truthfulness. For instance, women are told that if they breastfeed their babies will be smarter, healthier, and have stronger emotional bonds. However, when research studies control for factors such as mothers’ education level or the amount of time spent talking to the baby, the effect of breastfeeding on intelligence “washes out.”³ Babies who are formula-fed but cuddled experience the same degree of bonding with their mothers as breast-fed babies.^4,5

Although breast is best, the reported benefits that underlie Baby Friendly are overblown and oversold. When we explain to a woman why her newborn cannot spend a few hours in the nursery or why we cannot allow a pacifier, we are denying her the right to parent and make choices for herself and her baby, not acting in the best interest of the woman. We are in fact misrepresenting the truth. We are also acting paternalistic, propagating the long tradition of telling women that we know better about their reproductive health and choices.

Related article:
Women’s Preventive Services Initiative Guidelines provide consensus for practicing ObGyns

Breastfeeding still not fully accepted outside the hospital

The Baby Friendly rules restrict autonomy and prod women to breastfeed for the few days that they remain in the hospital postpartum. However, these women go home to societal and institutional systems that are deeply unsupportive of breastfeeding. In addition to being the birthplace for 98% of babies born in the United States, the health care industry is the single largest employer of US women.^6,7 There are 5 academic hospitals in the Boston area. After contacting the human resources department at each, I found that only 1 has a policy for their breastfeeding employees.

Women should not be forced to choose between breastfeeding and working, between taking a longer maternity leave (often unpaid and professionally detrimental) and shelving the breast pump. What we invest in reveals our values. When we require women to room-in without respecting their choices or needs, and when workplaces fail to provide reasonable flexibility and private space for breast-pumping employees, our values as a society are revealed.

Women and men, hospital users and hospital employees, need to insist that the principles of autonomy, respect for persons, truthfulness, and justice guide breastfeeding policy both within our hospitals and within our workplaces. We need to respect women and the choices that they make for themselves and their families. We need to allow women to decide to recover from their delivery without their baby constantly in arms’ reach. We need to ensure that our counseling and our policies are rooted in sound science and not influenced by passionate but biased perspectives.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Photo: Shutterstock

Many hospitals across the country have received designation as “Baby Friendly”; many other hospitals are in the process of seeking this designation. In order to be Baby Friendly, a hospital or birth center must prove they have implemented a set of 10 rules to encourage breastfeeding. As Baby Friendly USA puts it in their byline, it has become the gold standard of care.

Importantly, Baby Friendly fails to recognize that there is another equally crucial participant in any childbirth experience—the woman. Although childbirth is natural and usually healthy, it is not easy. Women commonly lose up to 1 L of blood during childbirth.¹ Labor can take 18 to 24 hours for a first-timer and about 12 to 18 hours for an encore performance, often disrupting at least1 entire night of sleep. The minimally invasive cesarean delivery continues to elude us, and women undergoing cesarean delivery must contend with a sizable incision and the additional pain and associated recovery.

Hospitals adopting the Baby Friendly rules must not allow formula, must prohibit pacifier use, and must go to great lengths to encourage rooming-in. Rooming-in means that the baby shares the same room as the new mother around-the-clock, which is reported to help the new mother distinguish sounds that indicate “feed me” from those that indicate a cool breeze. Rooming-in has been shown to be associated with a modest increase in breastfeeding²; however, women who are committed to breastfeeding likely room-in more often than women less committed to breastfeeding. Whether or not forcing the woman who is less committed to breastfeeding or the woman highly committed to breastfeeding who just wants a good night’s rest to room-in with her baby has a meaningful impact on breastfeeding remains unknown.

Are we violating ethics rules?

When hospitals adopt the Baby Friendly rules—policies that limit women’s choices for themselves and for their baby—we violate medical ethics principles regarding respect for autonomy, beneficence, and truthfulness. For instance, women are told that if they breastfeed their babies will be smarter, healthier, and have stronger emotional bonds. However, when research studies control for factors such as mothers’ education level or the amount of time spent talking to the baby, the effect of breastfeeding on intelligence “washes out.”³ Babies who are formula-fed but cuddled experience the same degree of bonding with their mothers as breast-fed babies.^4,5

Although breast is best, the reported benefits that underlie Baby Friendly are overblown and oversold. When we explain to a woman why her newborn cannot spend a few hours in the nursery or why we cannot allow a pacifier, we are denying her the right to parent and make choices for herself and her baby, not acting in the best interest of the woman. We are in fact misrepresenting the truth. We are also acting paternalistic, propagating the long tradition of telling women that we know better about their reproductive health and choices.

Related article:
Women’s Preventive Services Initiative Guidelines provide consensus for practicing ObGyns

Breastfeeding still not fully accepted outside the hospital

The Baby Friendly rules restrict autonomy and prod women to breastfeed for the few days that they remain in the hospital postpartum. However, these women go home to societal and institutional systems that are deeply unsupportive of breastfeeding. In addition to being the birthplace for 98% of babies born in the United States, the health care industry is the single largest employer of US women.^6,7 There are 5 academic hospitals in the Boston area. After contacting the human resources department at each, I found that only 1 has a policy for their breastfeeding employees.

Women should not be forced to choose between breastfeeding and working, between taking a longer maternity leave (often unpaid and professionally detrimental) and shelving the breast pump. What we invest in reveals our values. When we require women to room-in without respecting their choices or needs, and when workplaces fail to provide reasonable flexibility and private space for breast-pumping employees, our values as a society are revealed.

Women and men, hospital users and hospital employees, need to insist that the principles of autonomy, respect for persons, truthfulness, and justice guide breastfeeding policy both within our hospitals and within our workplaces. We need to respect women and the choices that they make for themselves and their families. We need to allow women to decide to recover from their delivery without their baby constantly in arms’ reach. We need to ensure that our counseling and our policies are rooted in sound science and not influenced by passionate but biased perspectives.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

As the population of patients with limited English proficiency increases throughout English-speaking countries, health care providers often need translator services. Medical translator smartphone applications (apps) are useful tools that can provide ad hoc translator services.

According to the US Census Bureau in 2015, more than 60 million individuals — about 19% of Americans — reported speaking a language other than English at home, and more than 25 million said that they speak English “less than very well.”^1,2 The top 5 non-English languages spoken at home were Spanish, French, Chinese, Tagalog, and Vietnamese, encompassing 72% of non-English speakers.

In the health care sector, translator services are essential for providing accurate and culturally competent care. Current options for translator services include face-to-face interpreters, phone-based translator services, and translator apps on mobile devices. In settings where face-to-face interpreters or phone-based translator services are not available, translator apps may provide reasonable alternatives. My colleagues, Dr. Amrin Khander and Dr. Sara Farag, and I identified and evaluated medical translator apps that are available from the Apple iTunes and Google Play stores to aid clinicians in using such apps during clinical encounters.³

Three types of translator apps

Preset medical phrase translator apps require the user to search for or find a question or statement in order to facilitate a conversation. With these types of apps, a health care provider can choose fully conjugated sentences, which then can be played or read back to the patient in the chosen translated language. Within this group of apps, Canopy Speak and Universal Doctor Speaker are highly accessible, since both apps are available from the Apple iTunes and Google Play stores and both are free.

Medical dictionary apps require the user to search for a medical term in one language to receive a translation in another language. These apps are less useful, but they can help providers find and define specific terms in a given language.

General language translator apps require the user to enter a term, statement, or question in one language and then provide a translation in another language. Google Translate and Vocre Translate are examples.

The top recommended translator apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ I hope the apps described here will help you enhance communication with your patients who have limited English proficiency.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

As the population of patients with limited English proficiency increases throughout English-speaking countries, health care providers often need translator services. Medical translator smartphone applications (apps) are useful tools that can provide ad hoc translator services.

According to the US Census Bureau in 2015, more than 60 million individuals — about 19% of Americans — reported speaking a language other than English at home, and more than 25 million said that they speak English “less than very well.”^1,2 The top 5 non-English languages spoken at home were Spanish, French, Chinese, Tagalog, and Vietnamese, encompassing 72% of non-English speakers.

In the health care sector, translator services are essential for providing accurate and culturally competent care. Current options for translator services include face-to-face interpreters, phone-based translator services, and translator apps on mobile devices. In settings where face-to-face interpreters or phone-based translator services are not available, translator apps may provide reasonable alternatives. My colleagues, Dr. Amrin Khander and Dr. Sara Farag, and I identified and evaluated medical translator apps that are available from the Apple iTunes and Google Play stores to aid clinicians in using such apps during clinical encounters.³

Three types of translator apps

Preset medical phrase translator apps require the user to search for or find a question or statement in order to facilitate a conversation. With these types of apps, a health care provider can choose fully conjugated sentences, which then can be played or read back to the patient in the chosen translated language. Within this group of apps, Canopy Speak and Universal Doctor Speaker are highly accessible, since both apps are available from the Apple iTunes and Google Play stores and both are free.

Medical dictionary apps require the user to search for a medical term in one language to receive a translation in another language. These apps are less useful, but they can help providers find and define specific terms in a given language.

General language translator apps require the user to enter a term, statement, or question in one language and then provide a translation in another language. Google Translate and Vocre Translate are examples.

The top recommended translator apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ I hope the apps described here will help you enhance communication with your patients who have limited English proficiency.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

As the population of patients with limited English proficiency increases throughout English-speaking countries, health care providers often need translator services. Medical translator smartphone applications (apps) are useful tools that can provide ad hoc translator services.

According to the US Census Bureau in 2015, more than 60 million individuals — about 19% of Americans — reported speaking a language other than English at home, and more than 25 million said that they speak English “less than very well.”^1,2 The top 5 non-English languages spoken at home were Spanish, French, Chinese, Tagalog, and Vietnamese, encompassing 72% of non-English speakers.

In the health care sector, translator services are essential for providing accurate and culturally competent care. Current options for translator services include face-to-face interpreters, phone-based translator services, and translator apps on mobile devices. In settings where face-to-face interpreters or phone-based translator services are not available, translator apps may provide reasonable alternatives. My colleagues, Dr. Amrin Khander and Dr. Sara Farag, and I identified and evaluated medical translator apps that are available from the Apple iTunes and Google Play stores to aid clinicians in using such apps during clinical encounters.³

Three types of translator apps

Preset medical phrase translator apps require the user to search for or find a question or statement in order to facilitate a conversation. With these types of apps, a health care provider can choose fully conjugated sentences, which then can be played or read back to the patient in the chosen translated language. Within this group of apps, Canopy Speak and Universal Doctor Speaker are highly accessible, since both apps are available from the Apple iTunes and Google Play stores and both are free.

Medical dictionary apps require the user to search for a medical term in one language to receive a translation in another language. These apps are less useful, but they can help providers find and define specific terms in a given language.

General language translator apps require the user to enter a term, statement, or question in one language and then provide a translation in another language. Google Translate and Vocre Translate are examples.

The top recommended translator apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ I hope the apps described here will help you enhance communication with your patients who have limited English proficiency.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Woman dies following cervical cone biopsy: $4.25M award  

A 46-year-old woman underwent a cervical cone biopsy at a Veterans Administration (VA) hospital on July 18. Following the test, significant bleeding occurred. The gynecologic surgeon attempted to control the hemorrhage by injecting ferric subsulfate (Monsel’s) solution into the patient’s vagina. The bleeding abated, but the patient went into hypovolemic shock. During emergency laparotomy, a uterine perforation and injuries to both uterine arteries were detected. A hysterectomy was performed to stop the hemorrhage. The patient improved at first, but developed sepsis, small-bowel necrosis, and other complications. A bowel resection procedure was performed on July 26. She died on September 5.

ESTATE'S CLAIM:
The surgeon’s actions were negligent. She removed too much tissue during the biopsy, injured the vaginal and uterine walls, and failed to timely diagnose and appropriately treat the injuries. The ferric subsulfate solution entered the abdominal cavity via the perforation, causing peritonitis and bowel injuries. A pathology report from the bowel resection surgery informed the surgeon that the bowel was not properly reconnected after the damaged portion was removed, but this condition was neither detected intraoperatively nor treated postoperatively.

DEFENDANTS' DEFENSE:
The surgeon moved for summary judgment, countering that, as a federal employee, she was exempt from personal liability for the services performed as an employee of the VA. That motion was denied. She then argued that injury to the vaginal/uterine wall is a known complication of the biopsy procedure.

VERDICT:
A $4.25 million Illinois verdict was returned in federal court.

Related article:
Reducing maternal mortality in the United States—Let’s get organized!

Needle stick not reported to patient

A woman delivered a baby assisted by an on-call ObGyn. When the baby developed fetal tachycardia, the ObGyn recommended expediting delivery and discussed various options and the risks of each option. The mother chose a vaginal forceps delivery. During the procedure, the mother experienced a 3rd-degree perineal laceration and a few minor lacerations, which were repaired. The mother was in pain, so the ObGyn performed a revision repair. During the procedure, the ObGyn accidentally stuck himself with a clean needle. He replaced the needle and changed his glove. The mother reported instant pain relief following revision and was discharged. After the needle incident, the ObGyn’s thumb became red and swollen, so he took antibiotics.

Two days after discharge, the patient reported to the ObGyn’s office with fever, pain, and a foul odor emanating from the surgery site. She was given the diagnosis of pelvic incisional cellulitis and was taken to the operating room for exploration and debridement. The patient developed septic shock and necrotizing fasciitis. She was placed on a ventilator and underwent 13 surgeries.

PATIENTS' CLAIM:
The ObGyn was negligent. The patient claimed breach of duty: the ObGyn did not disclose that his thumb was swollen and that he took antibiotics.

PHYSICIANS' DEFENSE:
There was no breach of duty. He did not feel the need to concern the patient about an injury to himself that did not affect her.

VERDICT:
A Kansas defense verdict was returned.

Related article:
2017 Update on infectious disease

Catheter removal, air embolism: $3.5M settlement

A 44-year-old woman underwent gynecologic surgery on April 22. She developed a rectovaginal fistula and other complications. Intravenous antibiotics were required and parenteral nutrition was delivered through a central venous catheter. On May 22, after a hospital nurse removed the catheter, an air embolism developed, causing a brain injury. The patient has a mental disability and residual leg tremors.

PATIENTS' CLAIM:
Because of the surgeon’s negligence during surgery, a fistula developed. The nurse negligently removed the catheter, causing the embolism.

DEFENDANTS' DEFENSE:
The case settled during the trial.

VERDICT:
A $3.5 million Illinois settlement was reached, including payments of $1 million from the surgeon and $2.5 million from the hospital.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Woman dies following cervical cone biopsy: $4.25M award  

A 46-year-old woman underwent a cervical cone biopsy at a Veterans Administration (VA) hospital on July 18. Following the test, significant bleeding occurred. The gynecologic surgeon attempted to control the hemorrhage by injecting ferric subsulfate (Monsel’s) solution into the patient’s vagina. The bleeding abated, but the patient went into hypovolemic shock. During emergency laparotomy, a uterine perforation and injuries to both uterine arteries were detected. A hysterectomy was performed to stop the hemorrhage. The patient improved at first, but developed sepsis, small-bowel necrosis, and other complications. A bowel resection procedure was performed on July 26. She died on September 5.

ESTATE'S CLAIM:
The surgeon’s actions were negligent. She removed too much tissue during the biopsy, injured the vaginal and uterine walls, and failed to timely diagnose and appropriately treat the injuries. The ferric subsulfate solution entered the abdominal cavity via the perforation, causing peritonitis and bowel injuries. A pathology report from the bowel resection surgery informed the surgeon that the bowel was not properly reconnected after the damaged portion was removed, but this condition was neither detected intraoperatively nor treated postoperatively.

DEFENDANTS' DEFENSE:
The surgeon moved for summary judgment, countering that, as a federal employee, she was exempt from personal liability for the services performed as an employee of the VA. That motion was denied. She then argued that injury to the vaginal/uterine wall is a known complication of the biopsy procedure.

VERDICT:
A $4.25 million Illinois verdict was returned in federal court.

Related article:
Reducing maternal mortality in the United States—Let’s get organized!

Needle stick not reported to patient

A woman delivered a baby assisted by an on-call ObGyn. When the baby developed fetal tachycardia, the ObGyn recommended expediting delivery and discussed various options and the risks of each option. The mother chose a vaginal forceps delivery. During the procedure, the mother experienced a 3rd-degree perineal laceration and a few minor lacerations, which were repaired. The mother was in pain, so the ObGyn performed a revision repair. During the procedure, the ObGyn accidentally stuck himself with a clean needle. He replaced the needle and changed his glove. The mother reported instant pain relief following revision and was discharged. After the needle incident, the ObGyn’s thumb became red and swollen, so he took antibiotics.

Two days after discharge, the patient reported to the ObGyn’s office with fever, pain, and a foul odor emanating from the surgery site. She was given the diagnosis of pelvic incisional cellulitis and was taken to the operating room for exploration and debridement. The patient developed septic shock and necrotizing fasciitis. She was placed on a ventilator and underwent 13 surgeries.

PATIENTS' CLAIM:
The ObGyn was negligent. The patient claimed breach of duty: the ObGyn did not disclose that his thumb was swollen and that he took antibiotics.

PHYSICIANS' DEFENSE:
There was no breach of duty. He did not feel the need to concern the patient about an injury to himself that did not affect her.

VERDICT:
A Kansas defense verdict was returned.

Related article:
2017 Update on infectious disease

Catheter removal, air embolism: $3.5M settlement

A 44-year-old woman underwent gynecologic surgery on April 22. She developed a rectovaginal fistula and other complications. Intravenous antibiotics were required and parenteral nutrition was delivered through a central venous catheter. On May 22, after a hospital nurse removed the catheter, an air embolism developed, causing a brain injury. The patient has a mental disability and residual leg tremors.

PATIENTS' CLAIM:
Because of the surgeon’s negligence during surgery, a fistula developed. The nurse negligently removed the catheter, causing the embolism.

DEFENDANTS' DEFENSE:
The case settled during the trial.

VERDICT:
A $3.5 million Illinois settlement was reached, including payments of $1 million from the surgeon and $2.5 million from the hospital.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Woman dies following cervical cone biopsy: $4.25M award  

A 46-year-old woman underwent a cervical cone biopsy at a Veterans Administration (VA) hospital on July 18. Following the test, significant bleeding occurred. The gynecologic surgeon attempted to control the hemorrhage by injecting ferric subsulfate (Monsel’s) solution into the patient’s vagina. The bleeding abated, but the patient went into hypovolemic shock. During emergency laparotomy, a uterine perforation and injuries to both uterine arteries were detected. A hysterectomy was performed to stop the hemorrhage. The patient improved at first, but developed sepsis, small-bowel necrosis, and other complications. A bowel resection procedure was performed on July 26. She died on September 5.

ESTATE'S CLAIM:
The surgeon’s actions were negligent. She removed too much tissue during the biopsy, injured the vaginal and uterine walls, and failed to timely diagnose and appropriately treat the injuries. The ferric subsulfate solution entered the abdominal cavity via the perforation, causing peritonitis and bowel injuries. A pathology report from the bowel resection surgery informed the surgeon that the bowel was not properly reconnected after the damaged portion was removed, but this condition was neither detected intraoperatively nor treated postoperatively.

DEFENDANTS' DEFENSE:
The surgeon moved for summary judgment, countering that, as a federal employee, she was exempt from personal liability for the services performed as an employee of the VA. That motion was denied. She then argued that injury to the vaginal/uterine wall is a known complication of the biopsy procedure.

VERDICT:
A $4.25 million Illinois verdict was returned in federal court.

Related article:
Reducing maternal mortality in the United States—Let’s get organized!

Needle stick not reported to patient

A woman delivered a baby assisted by an on-call ObGyn. When the baby developed fetal tachycardia, the ObGyn recommended expediting delivery and discussed various options and the risks of each option. The mother chose a vaginal forceps delivery. During the procedure, the mother experienced a 3rd-degree perineal laceration and a few minor lacerations, which were repaired. The mother was in pain, so the ObGyn performed a revision repair. During the procedure, the ObGyn accidentally stuck himself with a clean needle. He replaced the needle and changed his glove. The mother reported instant pain relief following revision and was discharged. After the needle incident, the ObGyn’s thumb became red and swollen, so he took antibiotics.

Two days after discharge, the patient reported to the ObGyn’s office with fever, pain, and a foul odor emanating from the surgery site. She was given the diagnosis of pelvic incisional cellulitis and was taken to the operating room for exploration and debridement. The patient developed septic shock and necrotizing fasciitis. She was placed on a ventilator and underwent 13 surgeries.

PATIENTS' CLAIM:
The ObGyn was negligent. The patient claimed breach of duty: the ObGyn did not disclose that his thumb was swollen and that he took antibiotics.

PHYSICIANS' DEFENSE:
There was no breach of duty. He did not feel the need to concern the patient about an injury to himself that did not affect her.

VERDICT:
A Kansas defense verdict was returned.

Related article:
2017 Update on infectious disease

Catheter removal, air embolism: $3.5M settlement

A 44-year-old woman underwent gynecologic surgery on April 22. She developed a rectovaginal fistula and other complications. Intravenous antibiotics were required and parenteral nutrition was delivered through a central venous catheter. On May 22, after a hospital nurse removed the catheter, an air embolism developed, causing a brain injury. The patient has a mental disability and residual leg tremors.

PATIENTS' CLAIM:
Because of the surgeon’s negligence during surgery, a fistula developed. The nurse negligently removed the catheter, causing the embolism.

DEFENDANTS' DEFENSE:
The case settled during the trial.

VERDICT:
A $3.5 million Illinois settlement was reached, including payments of $1 million from the surgeon and $2.5 million from the hospital.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CHICAGO – A study that compares babies who develop neonatal abstinence syndrome (NAS) with a control group of healthy newborns found largely what researchers expected to see – lower gestational ages, lower birth weights, and substance use in 100% of the mothers in the affected group. It’s when they looked at the control group of healthy newborns and their mothers that they got a surprise.

“Something that was very alarming in our study is [that] one in four of the control mothers was also positive for illicit drugs. That is something we definitely didn’t expect,” said Pallavi Karunakaran MD, a pediatric resident at Children’s Hospital of Michigan in Detroit.

Damian McNamara/Frontline Medical News

Dr. Karunakaran had no relevant financial disclosures.

CHICAGO – A study that compares babies who develop neonatal abstinence syndrome (NAS) with a control group of healthy newborns found largely what researchers expected to see – lower gestational ages, lower birth weights, and substance use in 100% of the mothers in the affected group. It’s when they looked at the control group of healthy newborns and their mothers that they got a surprise.

“Something that was very alarming in our study is [that] one in four of the control mothers was also positive for illicit drugs. That is something we definitely didn’t expect,” said Pallavi Karunakaran MD, a pediatric resident at Children’s Hospital of Michigan in Detroit.

Damian McNamara/Frontline Medical News

Dr. Karunakaran had no relevant financial disclosures.

CHICAGO – A study that compares babies who develop neonatal abstinence syndrome (NAS) with a control group of healthy newborns found largely what researchers expected to see – lower gestational ages, lower birth weights, and substance use in 100% of the mothers in the affected group. It’s when they looked at the control group of healthy newborns and their mothers that they got a surprise.

“Something that was very alarming in our study is [that] one in four of the control mothers was also positive for illicit drugs. That is something we definitely didn’t expect,” said Pallavi Karunakaran MD, a pediatric resident at Children’s Hospital of Michigan in Detroit.

Damian McNamara/Frontline Medical News

Dr. Karunakaran had no relevant financial disclosures.

Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).

ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).

“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”

The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.

The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.

“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.

Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.

“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”

[email protected]

Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).

ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).

“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”

The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.

The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.

“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.

Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.

“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”

[email protected]

Ob.gyns. and hospitals should have an organized and systematic treatment plan for postpartum hemorrhage, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG).

ACOG is recommending that obstetric care facilities post guidelines regarding the diagnosis methods and management techniques of postpartum hemorrhage. If postpartum hemorrhage is suspected, a physical exam should be performed to quickly inspect the uterus, cervix, vulva, and perineum to identify the source of bleeding. Once the cause has been identified, a treatment plan specific to the etiology of the bleeding can be implemented (Obstet Gynecol. 2017;130:e168-86).

“Less invasive methods should always be used first,” Aaron Caughey, MD, PhD, one of the coauthors of the practice bulletin, said in a statement. “If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother.”

The ACOG reVITALize program defines postpartum hemorrhage “as cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process,” which differs from more traditional definitions of postpartum hemorrhage that puts the blood loss at more than 500 mL after vaginal birth and more than 1,000 mL after cesarean delivery.

The unpredictable nature of postpartum hemorrhage and its potential for severe morbidity and mortality make identifying its risk factors a priority. Risk assessment tools have been shown to identify 60%-85% of patients who will experience a serious hemorrhagic event. Risk factors for postpartum hemorrhage can be made into a simple table that categorizes different factors into low, medium, or high risk categories and posted in obstetric care facilities.

“The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail,” said Dr. Caughey, professor and chair of obstetrics and gynecology at Oregon Health and Science University, Portland.

Prevention is one of the key strategies outlined for combating postpartum hemorrhage. Many clinicians and organizations advise active management of the third stage of labor to decrease the likelihood of women experiencing postpartum hemorrhage. This can be done by administering oxytocin, massaging the uterus, and traction of the umbilical cord. Oxytocin can be administered both intravenously and intramuscularly and presents the lowest risk of adverse affects.

“By implementing standard protocols, we can improve outcomes,” Dr. Caughey said. “And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary.”

[email protected]

A 48-hour course of postoperative cephalexin and metronidazole, plus typical preoperative antibiotics, cut surgical site infections by 59% in obese women who had a cesarean delivery.

The benefit of the additional postoperative treatment was driven by a significant, 69% risk reduction among women who had ruptured membranes, Amy M. Valent, DO, and her colleagues reported (JAMA. 2017;318[11]:1026-34). However, the authors noted, “tests for interaction between the intact membranes and [ruptured] subgroups and postpartum cephalexin-metronidazole were not statistically different and should not be interpreted as showing a difference in significance or effect size among the subgroups with and without [rupture].”

AngelIce/Thinkstock

[email protected]

A 48-hour course of postoperative cephalexin and metronidazole, plus typical preoperative antibiotics, cut surgical site infections by 59% in obese women who had a cesarean delivery.

The benefit of the additional postoperative treatment was driven by a significant, 69% risk reduction among women who had ruptured membranes, Amy M. Valent, DO, and her colleagues reported (JAMA. 2017;318[11]:1026-34). However, the authors noted, “tests for interaction between the intact membranes and [ruptured] subgroups and postpartum cephalexin-metronidazole were not statistically different and should not be interpreted as showing a difference in significance or effect size among the subgroups with and without [rupture].”

AngelIce/Thinkstock

[email protected]

A 48-hour course of postoperative cephalexin and metronidazole, plus typical preoperative antibiotics, cut surgical site infections by 59% in obese women who had a cesarean delivery.

The benefit of the additional postoperative treatment was driven by a significant, 69% risk reduction among women who had ruptured membranes, Amy M. Valent, DO, and her colleagues reported (JAMA. 2017;318[11]:1026-34). However, the authors noted, “tests for interaction between the intact membranes and [ruptured] subgroups and postpartum cephalexin-metronidazole were not statistically different and should not be interpreted as showing a difference in significance or effect size among the subgroups with and without [rupture].”

AngelIce/Thinkstock

[email protected]