Obstetrics

ST. PETE BEACH, FLA. — Periconceptional exposure to oral contraceptives was not associated with increased risk of adverse fetal outcomes in a recent prospective study.

None of the 45 woman who were exposed to oral contraceptives during the periconceptional period and were followed until after delivery gave birth to an infant with congenital malformations, compared with 6 of 225 controls.

The difference in the congenital malformation rate between the exposed group and control group was not significant, according to H.K. Ahn, M.D., and colleagues of the Motherisk Program at Sungkyunkwan University, Seoul, South Korea, during a poster presentation at the annual meeting of the Teratology Society.

The groups were also similar in regard to mean gestational age at delivery (39 weeks in both groups) and birth weight (3,257g in the exposed group, and 3,268g in the controls), the investigators said.

Women who were in the exposed group took oral contraceptives that contained either combined ethinyl estradiol and progesterone, or high-dose progesterone.

Although some earlier studies suggested a link between oral contraceptive use during pregnancy and increased risk of birth defects, later studies—including the current study—have failed to reproduce these findings.

“Exposure to oral contraceptives, including high doses of progesterone … did not increase adverse fetal outcomes,” the investigators said.

ST. PETE BEACH, FLA. — Periconceptional exposure to oral contraceptives was not associated with increased risk of adverse fetal outcomes in a recent prospective study.

None of the 45 woman who were exposed to oral contraceptives during the periconceptional period and were followed until after delivery gave birth to an infant with congenital malformations, compared with 6 of 225 controls.

The difference in the congenital malformation rate between the exposed group and control group was not significant, according to H.K. Ahn, M.D., and colleagues of the Motherisk Program at Sungkyunkwan University, Seoul, South Korea, during a poster presentation at the annual meeting of the Teratology Society.

The groups were also similar in regard to mean gestational age at delivery (39 weeks in both groups) and birth weight (3,257g in the exposed group, and 3,268g in the controls), the investigators said.

Women who were in the exposed group took oral contraceptives that contained either combined ethinyl estradiol and progesterone, or high-dose progesterone.

Although some earlier studies suggested a link between oral contraceptive use during pregnancy and increased risk of birth defects, later studies—including the current study—have failed to reproduce these findings.

“Exposure to oral contraceptives, including high doses of progesterone … did not increase adverse fetal outcomes,” the investigators said.

ST. PETE BEACH, FLA. — Periconceptional exposure to oral contraceptives was not associated with increased risk of adverse fetal outcomes in a recent prospective study.

None of the 45 woman who were exposed to oral contraceptives during the periconceptional period and were followed until after delivery gave birth to an infant with congenital malformations, compared with 6 of 225 controls.

The difference in the congenital malformation rate between the exposed group and control group was not significant, according to H.K. Ahn, M.D., and colleagues of the Motherisk Program at Sungkyunkwan University, Seoul, South Korea, during a poster presentation at the annual meeting of the Teratology Society.

The groups were also similar in regard to mean gestational age at delivery (39 weeks in both groups) and birth weight (3,257g in the exposed group, and 3,268g in the controls), the investigators said.

Women who were in the exposed group took oral contraceptives that contained either combined ethinyl estradiol and progesterone, or high-dose progesterone.

Although some earlier studies suggested a link between oral contraceptive use during pregnancy and increased risk of birth defects, later studies—including the current study—have failed to reproduce these findings.

“Exposure to oral contraceptives, including high doses of progesterone … did not increase adverse fetal outcomes,” the investigators said.

Women whose breast cancers were detected by screening mammography were 53% less likely to die of breast cancer over a 10- to 15-year period than those whose cancers were detected symptomatically, Donald Berry, Ph.D., and his colleagues have reported.

The study of more than 150,000 women doesn't mean that screening mammography is beneficial, however, Dr. Berry told this newspaper. The real reason behind the survival shift, he said, is that mammography picks up tumors that grow more slowly and are less biologically lethal than those discovered symptomatically.

Dr. Berry, chairman of the department of biostatistics and applied mathematics at the University of Texas, Houston, and his coinvestigators examined survival outcomes in three large North American breast cancer screening trials containing about 152,000 women: the breast cancer screening trial of the Health Insurance Plan of Greater New York (HIP) and two Canadian National Breast Screening Studies (CNBSS-1 and CNBSS-2).

The HIP screening was carried out in the 1960s, while both CNBSS trials were conducted in the 1980s. Follow-up ranged from 15 to 20 years (J. Natl. Cancer Inst. 2005;97:1195–203).

The researchers looked at the occurrence of screen-detected cancers, cancers detected in control groups (no screening mammography), and interval/incident cancers (cancers detected either less than 1 year or more than 1 year after the last negative screen).

There was a clear shift toward earlier stage cancers in the screening groups. In the HIP trial, 76% of screen-detected cancers were stage I, compared with 51% of interval/incident cancers and 49% of cancers in the control group. Control subjects and women who failed to attend their screenings had the highest percentage of stage III/IV cancers—14% and 22%, respectively.

In the CNBSS-1, 55% of screen-tested cancers, 40% of interval/incident cancers, and 47% of cancers in the control group were stage I. In the CNBSS-2, 62% of the screen-detected cancers, 44% of the interval/incident cancers, and 47% of the cancers in the control group were stage I. In both trials, the highest percentage of stage III/IV cancers occurred in the interval/incident group (about 20%).

Tumor sizes were smaller in the screening groups in all three studies; there was a significantly higher proportion of negative lymph nodes among women with screen-detected cancers in all three studies.

These characteristics reflect lead-time bias, Dr. Berry said, and he adjusted the analysis to compensate for this. However, even after adjustment for tumor characteristics, women whose cancers were detected by screening had the longest survival time. The relative risk of breast cancer death was 53% greater for women with interval/incident cancers and 36% greater for those in the control group with cancer, than were those for women with screen-detected cancers.

The survival advantage seems to arise from the mammogram's tendency to detect less aggressive tumors, he said. “Cancers found via screening include a higher proportion of slowly growing tumors, some of which might never be found by other means.” Paradoxically, this “overdiagnosis bias” means that the study cannot answer the question of whether screening mammography is beneficial.

“In addition to detecting the lethal tumors, screening also detects some [tumors] of the nonlethal variety,” Dr. Berry said. Some women with screen-detected nonlethal tumors may receive unnecessary surgery or other treatment, he said.

The investigators noted several limitations of the study. Since all women were screened in either the 1960s and the 1980s, the trials not only used less sophisticated mammographic techniques, but they also did not reflect tumor grading with modern biomarkers or the improved treatment techniques that are available today.

Women whose breast cancers were detected by screening mammography were 53% less likely to die of breast cancer over a 10- to 15-year period than those whose cancers were detected symptomatically, Donald Berry, Ph.D., and his colleagues have reported.

The study of more than 150,000 women doesn't mean that screening mammography is beneficial, however, Dr. Berry told this newspaper. The real reason behind the survival shift, he said, is that mammography picks up tumors that grow more slowly and are less biologically lethal than those discovered symptomatically.

Dr. Berry, chairman of the department of biostatistics and applied mathematics at the University of Texas, Houston, and his coinvestigators examined survival outcomes in three large North American breast cancer screening trials containing about 152,000 women: the breast cancer screening trial of the Health Insurance Plan of Greater New York (HIP) and two Canadian National Breast Screening Studies (CNBSS-1 and CNBSS-2).

The HIP screening was carried out in the 1960s, while both CNBSS trials were conducted in the 1980s. Follow-up ranged from 15 to 20 years (J. Natl. Cancer Inst. 2005;97:1195–203).

The researchers looked at the occurrence of screen-detected cancers, cancers detected in control groups (no screening mammography), and interval/incident cancers (cancers detected either less than 1 year or more than 1 year after the last negative screen).

There was a clear shift toward earlier stage cancers in the screening groups. In the HIP trial, 76% of screen-detected cancers were stage I, compared with 51% of interval/incident cancers and 49% of cancers in the control group. Control subjects and women who failed to attend their screenings had the highest percentage of stage III/IV cancers—14% and 22%, respectively.

In the CNBSS-1, 55% of screen-tested cancers, 40% of interval/incident cancers, and 47% of cancers in the control group were stage I. In the CNBSS-2, 62% of the screen-detected cancers, 44% of the interval/incident cancers, and 47% of the cancers in the control group were stage I. In both trials, the highest percentage of stage III/IV cancers occurred in the interval/incident group (about 20%).

Tumor sizes were smaller in the screening groups in all three studies; there was a significantly higher proportion of negative lymph nodes among women with screen-detected cancers in all three studies.

These characteristics reflect lead-time bias, Dr. Berry said, and he adjusted the analysis to compensate for this. However, even after adjustment for tumor characteristics, women whose cancers were detected by screening had the longest survival time. The relative risk of breast cancer death was 53% greater for women with interval/incident cancers and 36% greater for those in the control group with cancer, than were those for women with screen-detected cancers.

The survival advantage seems to arise from the mammogram's tendency to detect less aggressive tumors, he said. “Cancers found via screening include a higher proportion of slowly growing tumors, some of which might never be found by other means.” Paradoxically, this “overdiagnosis bias” means that the study cannot answer the question of whether screening mammography is beneficial.

“In addition to detecting the lethal tumors, screening also detects some [tumors] of the nonlethal variety,” Dr. Berry said. Some women with screen-detected nonlethal tumors may receive unnecessary surgery or other treatment, he said.

The investigators noted several limitations of the study. Since all women were screened in either the 1960s and the 1980s, the trials not only used less sophisticated mammographic techniques, but they also did not reflect tumor grading with modern biomarkers or the improved treatment techniques that are available today.

Women whose breast cancers were detected by screening mammography were 53% less likely to die of breast cancer over a 10- to 15-year period than those whose cancers were detected symptomatically, Donald Berry, Ph.D., and his colleagues have reported.

The study of more than 150,000 women doesn't mean that screening mammography is beneficial, however, Dr. Berry told this newspaper. The real reason behind the survival shift, he said, is that mammography picks up tumors that grow more slowly and are less biologically lethal than those discovered symptomatically.

Dr. Berry, chairman of the department of biostatistics and applied mathematics at the University of Texas, Houston, and his coinvestigators examined survival outcomes in three large North American breast cancer screening trials containing about 152,000 women: the breast cancer screening trial of the Health Insurance Plan of Greater New York (HIP) and two Canadian National Breast Screening Studies (CNBSS-1 and CNBSS-2).

The HIP screening was carried out in the 1960s, while both CNBSS trials were conducted in the 1980s. Follow-up ranged from 15 to 20 years (J. Natl. Cancer Inst. 2005;97:1195–203).

The researchers looked at the occurrence of screen-detected cancers, cancers detected in control groups (no screening mammography), and interval/incident cancers (cancers detected either less than 1 year or more than 1 year after the last negative screen).

There was a clear shift toward earlier stage cancers in the screening groups. In the HIP trial, 76% of screen-detected cancers were stage I, compared with 51% of interval/incident cancers and 49% of cancers in the control group. Control subjects and women who failed to attend their screenings had the highest percentage of stage III/IV cancers—14% and 22%, respectively.

In the CNBSS-1, 55% of screen-tested cancers, 40% of interval/incident cancers, and 47% of cancers in the control group were stage I. In the CNBSS-2, 62% of the screen-detected cancers, 44% of the interval/incident cancers, and 47% of the cancers in the control group were stage I. In both trials, the highest percentage of stage III/IV cancers occurred in the interval/incident group (about 20%).

Tumor sizes were smaller in the screening groups in all three studies; there was a significantly higher proportion of negative lymph nodes among women with screen-detected cancers in all three studies.

These characteristics reflect lead-time bias, Dr. Berry said, and he adjusted the analysis to compensate for this. However, even after adjustment for tumor characteristics, women whose cancers were detected by screening had the longest survival time. The relative risk of breast cancer death was 53% greater for women with interval/incident cancers and 36% greater for those in the control group with cancer, than were those for women with screen-detected cancers.

The survival advantage seems to arise from the mammogram's tendency to detect less aggressive tumors, he said. “Cancers found via screening include a higher proportion of slowly growing tumors, some of which might never be found by other means.” Paradoxically, this “overdiagnosis bias” means that the study cannot answer the question of whether screening mammography is beneficial.

“In addition to detecting the lethal tumors, screening also detects some [tumors] of the nonlethal variety,” Dr. Berry said. Some women with screen-detected nonlethal tumors may receive unnecessary surgery or other treatment, he said.

The investigators noted several limitations of the study. Since all women were screened in either the 1960s and the 1980s, the trials not only used less sophisticated mammographic techniques, but they also did not reflect tumor grading with modern biomarkers or the improved treatment techniques that are available today.

ASHEVILLE, N.C. — Though very rare, severe neurologic complications can occur as a result of spinal and epidural blocks for labor and delivery, and keeping an eye out for early symptoms can result in better outcomes, according to one expert.

Spinal hematoma, cauda equina syndrome, bacterial meningitis, and epidural abscess appear to be the most common severe neurologic complications, based on a study of 1,260,000 spinal blocks and 450,000 epidural blocks administered in Sweden between 1990 and 1999, said David C. Mayer, M.D., professor of anesthesiology at the University of North Carolina in Chapel Hill.

Complications occurred more often after placement of epidurals than spinal blocks. The study included 200,000 epidurals for pain relief during labor and 55,000 spinal blocks and epidurals for cesarean sections (Anesthesiology 2004;101:950–9).

“Spinal hematoma has a uniformly bad outcome,” Dr. Mayer said at the Southern Obstetric and Gynecologic seminar. In the study, 27 of the 33 spinal hematoma cases resulted in permanent neurologic damage.

Spinal or epidural hematoma is primarily associated with catheter technique. An indwelling catheter in the epidural space almost always is associated with epidural hematoma. Several other factors can come into play, including spine pathology, difficulty in performing the block, and altered coagulation.

With spine pathology, there may be an abnormal nerve route that increases the likelihood of hitting a blood vessel. Difficult blocks involve multiple sticks and increase the risk of hitting a blood vessel. Altered coagulation combined with catheter insertion or removal can lead to hematoma. “Removing an epidural catheter can be as traumatic as placing it,” Dr. Mayer said.

The key problem associated with epidural hematoma is the diagnosis. Back pain was considered the classic symptom of epidural hematoma, but motor block that does not resolve is now considered a better indicator. Consult an anesthesiologist and neurosurgeon right away if a patient has motor block that persists, is out of proportion for the pain medication given, or develops several days later.

According to a closed claims database that is maintained by the American Society of Anesthesiologists, 90% of neuraxial hematomas result in irreversible damage. Unfortunately, the diagnosis is made well after the onset of symptoms. There's only an 8-hour window between the onset of neurologic changes and laminectomy—the treatment of choice—to avoid any permanent damage. “For many patients, by the time they're evaluated completely, it's past the period in which anything can be done,” Dr. Mayer said.

Anticoagulation medication is now so common among patients receiving anesthesia that the American Society of Regional Anesthesia and Pain Medicine has developed a consensus statement on the use of regional anesthesia in anticoagulated patients (Reg. Anesth. Pain Med. 2003;28:172–97).

According to this guideline, there is no increased risk of hematoma when unfractionated heparin is used for subcutaneous prophylaxis. If the patient has been on this therapy for more than 4 days at the time of epidural placement, a platelet count is needed to rule out heparin-induced thrombocytopenia.

Low molecular weight heparins (LMWHs) are a different matter. LMWHs “have really changed how we give regional anesthesia in the anticoagulated patients,” said Dr. Mayer. If patients are on an LMWH before the epidural is placed, assume that the patient has altered coagulation. Delay needle placement by at least 10–12 hours after giving a dose of LMWH. However, in patients receiving higher doses—for example, 1 mg/kg enoxaparin every 12 hours—delay the epidural for at least 24 hours. “These patients have very abnormal coagulation,” Dr. Mayer said.

Cauda equina syndrome occurred nearly as often as spinal hematoma in the Swedish study but had worse outcomes, with all 32 cases resulting in permanent neurologic damage.

Cauda equina syndrome is characterized by lower extremity weakness or paralysis, bowel or bladder sphincter dysfunction, and saddle anesthesia.

The onset of symptoms can range from a couple of days to a couple of weeks. “It's a very insidious onset. … Once you get these findings, there's actually nothing that can be done, other than rehabilitation,” said Dr. Mayer, who is also a professor of obstetrics and gynecology at the university.

Cauda equina syndrome can be caused by massive disk herniation and compression of nerves. There have been case reports and small series of cases that implicate the use of hyperbaric lidocaine—potentially because of the preservative used or possibly even because of the lidocaine itself. “This is unclear, but a lot of anesthesiologists are hesitant to use any intrathecal lidocaine because of the risk of cauda equina syndrome,” Dr. Mayer said.

Preexisting spinal stenoses also appear to be associated with this syndrome. Spinal stenoses narrow the space in the spinal canal and impede the flow of the epidural, resulting in increased pressure on the nerves. If the patient is older and has vascular disease, ischemia can lead to cauda equina syndrome.

Infectious complications, such as bacterial meningitis and epidural abscess, have the most favorable outcomes, with most patients in the Swedish study making a full recovery.

The best medical outcomes rely on early diagnosis. Fever and backache are clearly the most common symptoms, although neurologic changes may be present as well.

Typically, it takes about 5 days for onset of symptoms. Staphylococcus species are the most commonly identified culprits. And treatment may include antibiotic therapy or even surgery to decompress the spinal cord.

Meningitis is exclusively related to spinal blocks and results from puncture of the dura. Typically, meningitis manifests within 24 hours as headache or neurologic changes.

“Early infectious processes are more likely to be meningitis than epidural abscesses,” Dr. Mayer said. In the Swedish study, streptococci were responsible for most of the meningitis cases.

ASHEVILLE, N.C. — Though very rare, severe neurologic complications can occur as a result of spinal and epidural blocks for labor and delivery, and keeping an eye out for early symptoms can result in better outcomes, according to one expert.

Spinal hematoma, cauda equina syndrome, bacterial meningitis, and epidural abscess appear to be the most common severe neurologic complications, based on a study of 1,260,000 spinal blocks and 450,000 epidural blocks administered in Sweden between 1990 and 1999, said David C. Mayer, M.D., professor of anesthesiology at the University of North Carolina in Chapel Hill.

Complications occurred more often after placement of epidurals than spinal blocks. The study included 200,000 epidurals for pain relief during labor and 55,000 spinal blocks and epidurals for cesarean sections (Anesthesiology 2004;101:950–9).

“Spinal hematoma has a uniformly bad outcome,” Dr. Mayer said at the Southern Obstetric and Gynecologic seminar. In the study, 27 of the 33 spinal hematoma cases resulted in permanent neurologic damage.

Spinal or epidural hematoma is primarily associated with catheter technique. An indwelling catheter in the epidural space almost always is associated with epidural hematoma. Several other factors can come into play, including spine pathology, difficulty in performing the block, and altered coagulation.

With spine pathology, there may be an abnormal nerve route that increases the likelihood of hitting a blood vessel. Difficult blocks involve multiple sticks and increase the risk of hitting a blood vessel. Altered coagulation combined with catheter insertion or removal can lead to hematoma. “Removing an epidural catheter can be as traumatic as placing it,” Dr. Mayer said.

The key problem associated with epidural hematoma is the diagnosis. Back pain was considered the classic symptom of epidural hematoma, but motor block that does not resolve is now considered a better indicator. Consult an anesthesiologist and neurosurgeon right away if a patient has motor block that persists, is out of proportion for the pain medication given, or develops several days later.

According to a closed claims database that is maintained by the American Society of Anesthesiologists, 90% of neuraxial hematomas result in irreversible damage. Unfortunately, the diagnosis is made well after the onset of symptoms. There's only an 8-hour window between the onset of neurologic changes and laminectomy—the treatment of choice—to avoid any permanent damage. “For many patients, by the time they're evaluated completely, it's past the period in which anything can be done,” Dr. Mayer said.

Anticoagulation medication is now so common among patients receiving anesthesia that the American Society of Regional Anesthesia and Pain Medicine has developed a consensus statement on the use of regional anesthesia in anticoagulated patients (Reg. Anesth. Pain Med. 2003;28:172–97).

According to this guideline, there is no increased risk of hematoma when unfractionated heparin is used for subcutaneous prophylaxis. If the patient has been on this therapy for more than 4 days at the time of epidural placement, a platelet count is needed to rule out heparin-induced thrombocytopenia.

Low molecular weight heparins (LMWHs) are a different matter. LMWHs “have really changed how we give regional anesthesia in the anticoagulated patients,” said Dr. Mayer. If patients are on an LMWH before the epidural is placed, assume that the patient has altered coagulation. Delay needle placement by at least 10–12 hours after giving a dose of LMWH. However, in patients receiving higher doses—for example, 1 mg/kg enoxaparin every 12 hours—delay the epidural for at least 24 hours. “These patients have very abnormal coagulation,” Dr. Mayer said.

Cauda equina syndrome occurred nearly as often as spinal hematoma in the Swedish study but had worse outcomes, with all 32 cases resulting in permanent neurologic damage.

Cauda equina syndrome is characterized by lower extremity weakness or paralysis, bowel or bladder sphincter dysfunction, and saddle anesthesia.

The onset of symptoms can range from a couple of days to a couple of weeks. “It's a very insidious onset. … Once you get these findings, there's actually nothing that can be done, other than rehabilitation,” said Dr. Mayer, who is also a professor of obstetrics and gynecology at the university.

Cauda equina syndrome can be caused by massive disk herniation and compression of nerves. There have been case reports and small series of cases that implicate the use of hyperbaric lidocaine—potentially because of the preservative used or possibly even because of the lidocaine itself. “This is unclear, but a lot of anesthesiologists are hesitant to use any intrathecal lidocaine because of the risk of cauda equina syndrome,” Dr. Mayer said.

Preexisting spinal stenoses also appear to be associated with this syndrome. Spinal stenoses narrow the space in the spinal canal and impede the flow of the epidural, resulting in increased pressure on the nerves. If the patient is older and has vascular disease, ischemia can lead to cauda equina syndrome.

Infectious complications, such as bacterial meningitis and epidural abscess, have the most favorable outcomes, with most patients in the Swedish study making a full recovery.

The best medical outcomes rely on early diagnosis. Fever and backache are clearly the most common symptoms, although neurologic changes may be present as well.

Typically, it takes about 5 days for onset of symptoms. Staphylococcus species are the most commonly identified culprits. And treatment may include antibiotic therapy or even surgery to decompress the spinal cord.

Meningitis is exclusively related to spinal blocks and results from puncture of the dura. Typically, meningitis manifests within 24 hours as headache or neurologic changes.

“Early infectious processes are more likely to be meningitis than epidural abscesses,” Dr. Mayer said. In the Swedish study, streptococci were responsible for most of the meningitis cases.

ASHEVILLE, N.C. — Though very rare, severe neurologic complications can occur as a result of spinal and epidural blocks for labor and delivery, and keeping an eye out for early symptoms can result in better outcomes, according to one expert.

Spinal hematoma, cauda equina syndrome, bacterial meningitis, and epidural abscess appear to be the most common severe neurologic complications, based on a study of 1,260,000 spinal blocks and 450,000 epidural blocks administered in Sweden between 1990 and 1999, said David C. Mayer, M.D., professor of anesthesiology at the University of North Carolina in Chapel Hill.

Complications occurred more often after placement of epidurals than spinal blocks. The study included 200,000 epidurals for pain relief during labor and 55,000 spinal blocks and epidurals for cesarean sections (Anesthesiology 2004;101:950–9).

“Spinal hematoma has a uniformly bad outcome,” Dr. Mayer said at the Southern Obstetric and Gynecologic seminar. In the study, 27 of the 33 spinal hematoma cases resulted in permanent neurologic damage.

Spinal or epidural hematoma is primarily associated with catheter technique. An indwelling catheter in the epidural space almost always is associated with epidural hematoma. Several other factors can come into play, including spine pathology, difficulty in performing the block, and altered coagulation.

With spine pathology, there may be an abnormal nerve route that increases the likelihood of hitting a blood vessel. Difficult blocks involve multiple sticks and increase the risk of hitting a blood vessel. Altered coagulation combined with catheter insertion or removal can lead to hematoma. “Removing an epidural catheter can be as traumatic as placing it,” Dr. Mayer said.

The key problem associated with epidural hematoma is the diagnosis. Back pain was considered the classic symptom of epidural hematoma, but motor block that does not resolve is now considered a better indicator. Consult an anesthesiologist and neurosurgeon right away if a patient has motor block that persists, is out of proportion for the pain medication given, or develops several days later.

According to a closed claims database that is maintained by the American Society of Anesthesiologists, 90% of neuraxial hematomas result in irreversible damage. Unfortunately, the diagnosis is made well after the onset of symptoms. There's only an 8-hour window between the onset of neurologic changes and laminectomy—the treatment of choice—to avoid any permanent damage. “For many patients, by the time they're evaluated completely, it's past the period in which anything can be done,” Dr. Mayer said.

Anticoagulation medication is now so common among patients receiving anesthesia that the American Society of Regional Anesthesia and Pain Medicine has developed a consensus statement on the use of regional anesthesia in anticoagulated patients (Reg. Anesth. Pain Med. 2003;28:172–97).

According to this guideline, there is no increased risk of hematoma when unfractionated heparin is used for subcutaneous prophylaxis. If the patient has been on this therapy for more than 4 days at the time of epidural placement, a platelet count is needed to rule out heparin-induced thrombocytopenia.

Low molecular weight heparins (LMWHs) are a different matter. LMWHs “have really changed how we give regional anesthesia in the anticoagulated patients,” said Dr. Mayer. If patients are on an LMWH before the epidural is placed, assume that the patient has altered coagulation. Delay needle placement by at least 10–12 hours after giving a dose of LMWH. However, in patients receiving higher doses—for example, 1 mg/kg enoxaparin every 12 hours—delay the epidural for at least 24 hours. “These patients have very abnormal coagulation,” Dr. Mayer said.

Cauda equina syndrome occurred nearly as often as spinal hematoma in the Swedish study but had worse outcomes, with all 32 cases resulting in permanent neurologic damage.

Cauda equina syndrome is characterized by lower extremity weakness or paralysis, bowel or bladder sphincter dysfunction, and saddle anesthesia.

The onset of symptoms can range from a couple of days to a couple of weeks. “It's a very insidious onset. … Once you get these findings, there's actually nothing that can be done, other than rehabilitation,” said Dr. Mayer, who is also a professor of obstetrics and gynecology at the university.

Cauda equina syndrome can be caused by massive disk herniation and compression of nerves. There have been case reports and small series of cases that implicate the use of hyperbaric lidocaine—potentially because of the preservative used or possibly even because of the lidocaine itself. “This is unclear, but a lot of anesthesiologists are hesitant to use any intrathecal lidocaine because of the risk of cauda equina syndrome,” Dr. Mayer said.

Preexisting spinal stenoses also appear to be associated with this syndrome. Spinal stenoses narrow the space in the spinal canal and impede the flow of the epidural, resulting in increased pressure on the nerves. If the patient is older and has vascular disease, ischemia can lead to cauda equina syndrome.

Infectious complications, such as bacterial meningitis and epidural abscess, have the most favorable outcomes, with most patients in the Swedish study making a full recovery.

The best medical outcomes rely on early diagnosis. Fever and backache are clearly the most common symptoms, although neurologic changes may be present as well.

Typically, it takes about 5 days for onset of symptoms. Staphylococcus species are the most commonly identified culprits. And treatment may include antibiotic therapy or even surgery to decompress the spinal cord.

Meningitis is exclusively related to spinal blocks and results from puncture of the dura. Typically, meningitis manifests within 24 hours as headache or neurologic changes.

“Early infectious processes are more likely to be meningitis than epidural abscesses,” Dr. Mayer said. In the Swedish study, streptococci were responsible for most of the meningitis cases.

The gradual rise in the cesarean section rate over the past 4 decades and the recent trend favoring repeat cesarean section rather than vaginal birth after cesarean is resulting in more women undergoing multiple cesarean sections.

What are the risks?

Recent case reports indicate that abnormal placentation (placenta previa and placenta accreta) and surgical time are increasing for women undergoing their 4th cesarean section, but there has been little increase in major operative complications or adverse perinatal outcomes.^1,2

Interestingly, most of the literature on this subject is from outside the United States, suggesting that clinicians in other countries have more and longer experience with 4th cesarean sections. In the United States, there is a widely held sentiment among clinicians that the first repeat cesarean section seldom presents a surgical problem, but that by the time a woman undergoes a 4th cesarean section, operative complications are common, including difficult dissections, major bleeding, and bladder or bowel injury.

Steps to reduce risk

Although the best clinical approach to a 4th cesarean has not been determined in clinical trials, many clinicians take specific steps to reduce the operative risk.

As with all cesarean sections, a 4th procedure should be preceded by a consent process that outlines the possibility of hysterectomy and injury to bowel and urinary systems, an anesthesia consult, baseline hemoglobin, use of nonparticulate antacid before the surgery, and antibiotic prophylaxis.³

Special precautions

A 4th cesarean section probably warrants additional precautions in many cases:

• Ensure an active blood sample is available in the blood bank (blood type and antibody screen) in case transfusion is necessary.
• Insert a 3-way Foley in case the bladder or adjacent structures are injured and bladder integrity needs to be tested.
• Consider a non-Pfannenstiel incision such as a Maylard or vertical incision to allow for more extensive dissection of adhesions and restoration of intraabdominal anatomy to safely complete the cesarean.
• Ensure immediate availability of medications to reduce intraoperative bleeding such as oxytocin, methergine, injectable prostaglandins such as carboprost, and misoprostol.
• Consider having available hemostatic agents such as FloSeal (Baxter Healthcare, Deerfield, Ill),Gelfoam (Pharmacia & Upjohn, Kalamazoo, Mich), or thrombin.
• Use techniques to reduce perioperative deep venous thrombosis, such as compression stockings or lower extremity intermittent compression devices.
• Consider a tubal ligation at the time of the 4th cesarean section.

If postpartum hemorrhage occurs, the clinical team may need to be prepared to perform uterine packing or tamponade (SOS Bakri Tamponade Balloon, Cook

Ob/Gyn Inc, Spencer, Ind), internal iliac artery ligation, selective uterine artery embolization, a B-Lynch suture, aortic compression, and/or hysterectomy.

Placenta location a concern

The location of the placenta may strongly influence the surgical approach. Placenta previa occurs more commonly in women with multiple previous cesarean sections.³ If placenta previa is present, the risk of placenta accreta, a life-threatening condition, increases with each previous cesarean birth.⁴ This markedly increases risk for major bleeding and hysterectomy. Consequently, an effort should be made to determine the location of the placenta and the possibility of a placenta accreta prior to the 4th cesarean section. If a placenta previa is present, preoperative placement of bilateral uterine artery balloon catheters may help reduce blood loss at the time of surgery. In addition, preoperative preparation for a potential complicated hysterectomy is a must.

What’s your experience?

The cesarean “4-Peat” is becoming more common, and it challenges the entire medical care team. We are interested in the experiences and innovative surgical techniques that our readers use when performing a 4th cesarean section. Please write to us with your suggestions for preventing adverse outcomes in these complicated cases.

REFERENCES

1. Juntunen K, Makarainen L, Kirkinen P. Outcome after a high number (4–10) of repeated cesarean sections. BJOG. 2004;111:561-563.

2. Rashid M, Rashid RS. Higher order repeat cesarean sections: how safe are five or more? BJOG. 2004;111:1090-1094.

3. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev. 2000;(2):CD000933.-

4. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol. 1985;66:89-92.

The gradual rise in the cesarean section rate over the past 4 decades and the recent trend favoring repeat cesarean section rather than vaginal birth after cesarean is resulting in more women undergoing multiple cesarean sections.

What are the risks?

Recent case reports indicate that abnormal placentation (placenta previa and placenta accreta) and surgical time are increasing for women undergoing their 4th cesarean section, but there has been little increase in major operative complications or adverse perinatal outcomes.^1,2

Interestingly, most of the literature on this subject is from outside the United States, suggesting that clinicians in other countries have more and longer experience with 4th cesarean sections. In the United States, there is a widely held sentiment among clinicians that the first repeat cesarean section seldom presents a surgical problem, but that by the time a woman undergoes a 4th cesarean section, operative complications are common, including difficult dissections, major bleeding, and bladder or bowel injury.

Steps to reduce risk

Although the best clinical approach to a 4th cesarean has not been determined in clinical trials, many clinicians take specific steps to reduce the operative risk.

As with all cesarean sections, a 4th procedure should be preceded by a consent process that outlines the possibility of hysterectomy and injury to bowel and urinary systems, an anesthesia consult, baseline hemoglobin, use of nonparticulate antacid before the surgery, and antibiotic prophylaxis.³

Special precautions

A 4th cesarean section probably warrants additional precautions in many cases:

• Ensure an active blood sample is available in the blood bank (blood type and antibody screen) in case transfusion is necessary.
• Insert a 3-way Foley in case the bladder or adjacent structures are injured and bladder integrity needs to be tested.
• Consider a non-Pfannenstiel incision such as a Maylard or vertical incision to allow for more extensive dissection of adhesions and restoration of intraabdominal anatomy to safely complete the cesarean.
• Ensure immediate availability of medications to reduce intraoperative bleeding such as oxytocin, methergine, injectable prostaglandins such as carboprost, and misoprostol.
• Consider having available hemostatic agents such as FloSeal (Baxter Healthcare, Deerfield, Ill),Gelfoam (Pharmacia & Upjohn, Kalamazoo, Mich), or thrombin.
• Use techniques to reduce perioperative deep venous thrombosis, such as compression stockings or lower extremity intermittent compression devices.
• Consider a tubal ligation at the time of the 4th cesarean section.

If postpartum hemorrhage occurs, the clinical team may need to be prepared to perform uterine packing or tamponade (SOS Bakri Tamponade Balloon, Cook

Ob/Gyn Inc, Spencer, Ind), internal iliac artery ligation, selective uterine artery embolization, a B-Lynch suture, aortic compression, and/or hysterectomy.

Placenta location a concern

The location of the placenta may strongly influence the surgical approach. Placenta previa occurs more commonly in women with multiple previous cesarean sections.³ If placenta previa is present, the risk of placenta accreta, a life-threatening condition, increases with each previous cesarean birth.⁴ This markedly increases risk for major bleeding and hysterectomy. Consequently, an effort should be made to determine the location of the placenta and the possibility of a placenta accreta prior to the 4th cesarean section. If a placenta previa is present, preoperative placement of bilateral uterine artery balloon catheters may help reduce blood loss at the time of surgery. In addition, preoperative preparation for a potential complicated hysterectomy is a must.

What’s your experience?

The cesarean “4-Peat” is becoming more common, and it challenges the entire medical care team. We are interested in the experiences and innovative surgical techniques that our readers use when performing a 4th cesarean section. Please write to us with your suggestions for preventing adverse outcomes in these complicated cases.

REFERENCES

1. Juntunen K, Makarainen L, Kirkinen P. Outcome after a high number (4–10) of repeated cesarean sections. BJOG. 2004;111:561-563.

2. Rashid M, Rashid RS. Higher order repeat cesarean sections: how safe are five or more? BJOG. 2004;111:1090-1094.

3. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev. 2000;(2):CD000933.-

4. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol. 1985;66:89-92.

The gradual rise in the cesarean section rate over the past 4 decades and the recent trend favoring repeat cesarean section rather than vaginal birth after cesarean is resulting in more women undergoing multiple cesarean sections.

What are the risks?

Recent case reports indicate that abnormal placentation (placenta previa and placenta accreta) and surgical time are increasing for women undergoing their 4th cesarean section, but there has been little increase in major operative complications or adverse perinatal outcomes.^1,2

Interestingly, most of the literature on this subject is from outside the United States, suggesting that clinicians in other countries have more and longer experience with 4th cesarean sections. In the United States, there is a widely held sentiment among clinicians that the first repeat cesarean section seldom presents a surgical problem, but that by the time a woman undergoes a 4th cesarean section, operative complications are common, including difficult dissections, major bleeding, and bladder or bowel injury.

Steps to reduce risk

Although the best clinical approach to a 4th cesarean has not been determined in clinical trials, many clinicians take specific steps to reduce the operative risk.

As with all cesarean sections, a 4th procedure should be preceded by a consent process that outlines the possibility of hysterectomy and injury to bowel and urinary systems, an anesthesia consult, baseline hemoglobin, use of nonparticulate antacid before the surgery, and antibiotic prophylaxis.³

Special precautions

A 4th cesarean section probably warrants additional precautions in many cases:

• Ensure an active blood sample is available in the blood bank (blood type and antibody screen) in case transfusion is necessary.
• Insert a 3-way Foley in case the bladder or adjacent structures are injured and bladder integrity needs to be tested.
• Consider a non-Pfannenstiel incision such as a Maylard or vertical incision to allow for more extensive dissection of adhesions and restoration of intraabdominal anatomy to safely complete the cesarean.
• Ensure immediate availability of medications to reduce intraoperative bleeding such as oxytocin, methergine, injectable prostaglandins such as carboprost, and misoprostol.
• Consider having available hemostatic agents such as FloSeal (Baxter Healthcare, Deerfield, Ill),Gelfoam (Pharmacia & Upjohn, Kalamazoo, Mich), or thrombin.
• Use techniques to reduce perioperative deep venous thrombosis, such as compression stockings or lower extremity intermittent compression devices.
• Consider a tubal ligation at the time of the 4th cesarean section.

If postpartum hemorrhage occurs, the clinical team may need to be prepared to perform uterine packing or tamponade (SOS Bakri Tamponade Balloon, Cook

Ob/Gyn Inc, Spencer, Ind), internal iliac artery ligation, selective uterine artery embolization, a B-Lynch suture, aortic compression, and/or hysterectomy.

Placenta location a concern

The location of the placenta may strongly influence the surgical approach. Placenta previa occurs more commonly in women with multiple previous cesarean sections.³ If placenta previa is present, the risk of placenta accreta, a life-threatening condition, increases with each previous cesarean birth.⁴ This markedly increases risk for major bleeding and hysterectomy. Consequently, an effort should be made to determine the location of the placenta and the possibility of a placenta accreta prior to the 4th cesarean section. If a placenta previa is present, preoperative placement of bilateral uterine artery balloon catheters may help reduce blood loss at the time of surgery. In addition, preoperative preparation for a potential complicated hysterectomy is a must.

What’s your experience?

The cesarean “4-Peat” is becoming more common, and it challenges the entire medical care team. We are interested in the experiences and innovative surgical techniques that our readers use when performing a 4th cesarean section. Please write to us with your suggestions for preventing adverse outcomes in these complicated cases.

REFERENCES

1. Juntunen K, Makarainen L, Kirkinen P. Outcome after a high number (4–10) of repeated cesarean sections. BJOG. 2004;111:561-563.

2. Rashid M, Rashid RS. Higher order repeat cesarean sections: how safe are five or more? BJOG. 2004;111:1090-1094.

3. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev. 2000;(2):CD000933.-

4. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol. 1985;66:89-92.

A pregnant woman's exposure to secondhand cigarette smoke may be just as risky to the fetus as is active smoking, according to a pooled data reanalysis conducted by Stephen G. Grant, Ph.D., of the University of Pittsburgh.

“This analysis shows not only that smoking during pregnancy causes genetic damage in the developing fetus that can be detected at birth, but also that passive, or secondary, exposure causes just as much damage as active smoking, and it's the same kind of damage,” Dr. Grant said in a statement.

In an interview, he said, “The women who go to the trouble of quitting smoking feel they have taken care of the problem. This is a cautionary exercise in which we say women have to change their lifestyles in other ways” such as having their husbands quit smoking and not going outside with their friends on smoke breaks even if they don't smoke themselves.

The analysis examined data from two contradictory studies on rates of mutation at the HPRT locus (a measure of in vivo mutagenesis) in newborn cord blood samples. Compared with samples from babies who had not been exposed to smoke in utero, exposed babies had significantly higher mutation rates. There were no significant differences in levels of induced mutation among children of exposed women (active smokers, women who had quit smoking when they learned they were pregnant, and women who were only passively exposed to smoke).

In the pooled data, the median HPRT mutation frequencies for actively and passively smoking mothers were both 0.87. The median for those who had quit smoking was 0.91, and for unexposed women, 0.60 (BMC Pediatr. 2005;5:20 [Epub ahead of print]).

A pregnant woman's exposure to secondhand cigarette smoke may be just as risky to the fetus as is active smoking, according to a pooled data reanalysis conducted by Stephen G. Grant, Ph.D., of the University of Pittsburgh.

“This analysis shows not only that smoking during pregnancy causes genetic damage in the developing fetus that can be detected at birth, but also that passive, or secondary, exposure causes just as much damage as active smoking, and it's the same kind of damage,” Dr. Grant said in a statement.

In an interview, he said, “The women who go to the trouble of quitting smoking feel they have taken care of the problem. This is a cautionary exercise in which we say women have to change their lifestyles in other ways” such as having their husbands quit smoking and not going outside with their friends on smoke breaks even if they don't smoke themselves.

The analysis examined data from two contradictory studies on rates of mutation at the HPRT locus (a measure of in vivo mutagenesis) in newborn cord blood samples. Compared with samples from babies who had not been exposed to smoke in utero, exposed babies had significantly higher mutation rates. There were no significant differences in levels of induced mutation among children of exposed women (active smokers, women who had quit smoking when they learned they were pregnant, and women who were only passively exposed to smoke).

In the pooled data, the median HPRT mutation frequencies for actively and passively smoking mothers were both 0.87. The median for those who had quit smoking was 0.91, and for unexposed women, 0.60 (BMC Pediatr. 2005;5:20 [Epub ahead of print]).

A pregnant woman's exposure to secondhand cigarette smoke may be just as risky to the fetus as is active smoking, according to a pooled data reanalysis conducted by Stephen G. Grant, Ph.D., of the University of Pittsburgh.

“This analysis shows not only that smoking during pregnancy causes genetic damage in the developing fetus that can be detected at birth, but also that passive, or secondary, exposure causes just as much damage as active smoking, and it's the same kind of damage,” Dr. Grant said in a statement.

In an interview, he said, “The women who go to the trouble of quitting smoking feel they have taken care of the problem. This is a cautionary exercise in which we say women have to change their lifestyles in other ways” such as having their husbands quit smoking and not going outside with their friends on smoke breaks even if they don't smoke themselves.

The analysis examined data from two contradictory studies on rates of mutation at the HPRT locus (a measure of in vivo mutagenesis) in newborn cord blood samples. Compared with samples from babies who had not been exposed to smoke in utero, exposed babies had significantly higher mutation rates. There were no significant differences in levels of induced mutation among children of exposed women (active smokers, women who had quit smoking when they learned they were pregnant, and women who were only passively exposed to smoke).

In the pooled data, the median HPRT mutation frequencies for actively and passively smoking mothers were both 0.87. The median for those who had quit smoking was 0.91, and for unexposed women, 0.60 (BMC Pediatr. 2005;5:20 [Epub ahead of print]).

QUEBEC CITY — Oral misoprostol appears to be as effective as oxytocin by injection in reducing blood loss at delivery, but is associated with an increased need for additional oxytocic drugs, according to a randomized, controlled trial presented in poster format at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Oral misoprostol may be used to reduce postpartum bleeding, particularly in areas where injectable oxytocic drugs are unavailable,” reported lead investigator Thomas Baskett, M.B., professor of obstetrics and gynecology at Dalhousie University in Halifax, Nova Scotia.

The synthetic PGE1 analogue has the advantage of being a cheap, stable, and orally administered uterotonic agent. “The main application for this is in developing countries, where they don't have personnel looking after women who can inject, or where there is no equipment or oxytocics to do so,” he said in an interview, adding that it might also have applications in rural communities if injectable oxytocics were not available.

Misoprostol has a role as second-line therapy if other injectables fail. “You might not use it routinely for active management of the third stage to reduce or prevent blood loss, but if bleeding occurs, then you can give misoprostol either orally or rectally with ease, and it's easy to have it stored in nursing stations or hospitals,” he said.

To assess efficacy of both agents, he and his colleagues compared 311 women given 400 mcg of oral misoprostol and 311 women who were given intravenous oxytocin, 5 units given after delivery of the anterior shoulder of the fetus. Researchers looked at women who had cephalic presentation and delivered vaginally, between 2000 and 2003 at the IWK Health Centre in Halifax. Those who had a multiple pregnancy, placenta previa, abruptio placentae, coagulation abnormalities, cesarean section, or severe asthma were excluded.

The primary outcome of at least a 10% drop in hematocrit at 24 hours' post partum was not clinically or statistically significantly different between the groups, and occurred in 10 of 291 (3.4%) of oxytocin patients, compared with 11 of 294 (3.7%) in the misoprostol group.

A total of 20 patients in the intravenous oxytocin group and 17 in the oral misoprostol group had missing hematocrit and hemoglobin values.

Of the secondary outcomes, 8.9% of oxytocin patients had a hematocrit drop of at least 30%, compared with 10.2% of patients in the misoprostol group.

Blood loss that was greater than 1,000 mL occurred in 2.3% of the oxytocin group and 4.5% of the misoprostol group. Additional uterotonics were required in 40.5% of those in the oxytocin group compared with 51.1% of those in the oral misoprostol group.

Researchers noted that the number of patients receiving additional oxytocics was high in both groups, and this was most likely due to the prevailing routine at the hospital of giving an intravenous infusion of oxytocin following the initial bolus dose at delivery.

Side effects of shivering and fever were present only in patients in the misoprostol group at the dose used, but were not clinically troublesome, the researchers noted. “Most of the trials that have found often upsetting shivering were with 600 mcg, and our study was with 400 mcg,” Dr. Baskett said in an interview.

The study was conducted to substantiate that it is reasonable to use the 400-mcg dose if the local circumstances and resources dictate that it be used, he noted.

QUEBEC CITY — Oral misoprostol appears to be as effective as oxytocin by injection in reducing blood loss at delivery, but is associated with an increased need for additional oxytocic drugs, according to a randomized, controlled trial presented in poster format at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Oral misoprostol may be used to reduce postpartum bleeding, particularly in areas where injectable oxytocic drugs are unavailable,” reported lead investigator Thomas Baskett, M.B., professor of obstetrics and gynecology at Dalhousie University in Halifax, Nova Scotia.

The synthetic PGE1 analogue has the advantage of being a cheap, stable, and orally administered uterotonic agent. “The main application for this is in developing countries, where they don't have personnel looking after women who can inject, or where there is no equipment or oxytocics to do so,” he said in an interview, adding that it might also have applications in rural communities if injectable oxytocics were not available.

Misoprostol has a role as second-line therapy if other injectables fail. “You might not use it routinely for active management of the third stage to reduce or prevent blood loss, but if bleeding occurs, then you can give misoprostol either orally or rectally with ease, and it's easy to have it stored in nursing stations or hospitals,” he said.

To assess efficacy of both agents, he and his colleagues compared 311 women given 400 mcg of oral misoprostol and 311 women who were given intravenous oxytocin, 5 units given after delivery of the anterior shoulder of the fetus. Researchers looked at women who had cephalic presentation and delivered vaginally, between 2000 and 2003 at the IWK Health Centre in Halifax. Those who had a multiple pregnancy, placenta previa, abruptio placentae, coagulation abnormalities, cesarean section, or severe asthma were excluded.

The primary outcome of at least a 10% drop in hematocrit at 24 hours' post partum was not clinically or statistically significantly different between the groups, and occurred in 10 of 291 (3.4%) of oxytocin patients, compared with 11 of 294 (3.7%) in the misoprostol group.

A total of 20 patients in the intravenous oxytocin group and 17 in the oral misoprostol group had missing hematocrit and hemoglobin values.

Of the secondary outcomes, 8.9% of oxytocin patients had a hematocrit drop of at least 30%, compared with 10.2% of patients in the misoprostol group.

Blood loss that was greater than 1,000 mL occurred in 2.3% of the oxytocin group and 4.5% of the misoprostol group. Additional uterotonics were required in 40.5% of those in the oxytocin group compared with 51.1% of those in the oral misoprostol group.

Researchers noted that the number of patients receiving additional oxytocics was high in both groups, and this was most likely due to the prevailing routine at the hospital of giving an intravenous infusion of oxytocin following the initial bolus dose at delivery.

Side effects of shivering and fever were present only in patients in the misoprostol group at the dose used, but were not clinically troublesome, the researchers noted. “Most of the trials that have found often upsetting shivering were with 600 mcg, and our study was with 400 mcg,” Dr. Baskett said in an interview.

The study was conducted to substantiate that it is reasonable to use the 400-mcg dose if the local circumstances and resources dictate that it be used, he noted.

QUEBEC CITY — Oral misoprostol appears to be as effective as oxytocin by injection in reducing blood loss at delivery, but is associated with an increased need for additional oxytocic drugs, according to a randomized, controlled trial presented in poster format at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Oral misoprostol may be used to reduce postpartum bleeding, particularly in areas where injectable oxytocic drugs are unavailable,” reported lead investigator Thomas Baskett, M.B., professor of obstetrics and gynecology at Dalhousie University in Halifax, Nova Scotia.

The synthetic PGE1 analogue has the advantage of being a cheap, stable, and orally administered uterotonic agent. “The main application for this is in developing countries, where they don't have personnel looking after women who can inject, or where there is no equipment or oxytocics to do so,” he said in an interview, adding that it might also have applications in rural communities if injectable oxytocics were not available.

Misoprostol has a role as second-line therapy if other injectables fail. “You might not use it routinely for active management of the third stage to reduce or prevent blood loss, but if bleeding occurs, then you can give misoprostol either orally or rectally with ease, and it's easy to have it stored in nursing stations or hospitals,” he said.

To assess efficacy of both agents, he and his colleagues compared 311 women given 400 mcg of oral misoprostol and 311 women who were given intravenous oxytocin, 5 units given after delivery of the anterior shoulder of the fetus. Researchers looked at women who had cephalic presentation and delivered vaginally, between 2000 and 2003 at the IWK Health Centre in Halifax. Those who had a multiple pregnancy, placenta previa, abruptio placentae, coagulation abnormalities, cesarean section, or severe asthma were excluded.

The primary outcome of at least a 10% drop in hematocrit at 24 hours' post partum was not clinically or statistically significantly different between the groups, and occurred in 10 of 291 (3.4%) of oxytocin patients, compared with 11 of 294 (3.7%) in the misoprostol group.

A total of 20 patients in the intravenous oxytocin group and 17 in the oral misoprostol group had missing hematocrit and hemoglobin values.

Of the secondary outcomes, 8.9% of oxytocin patients had a hematocrit drop of at least 30%, compared with 10.2% of patients in the misoprostol group.

Blood loss that was greater than 1,000 mL occurred in 2.3% of the oxytocin group and 4.5% of the misoprostol group. Additional uterotonics were required in 40.5% of those in the oxytocin group compared with 51.1% of those in the oral misoprostol group.

Researchers noted that the number of patients receiving additional oxytocics was high in both groups, and this was most likely due to the prevailing routine at the hospital of giving an intravenous infusion of oxytocin following the initial bolus dose at delivery.

Side effects of shivering and fever were present only in patients in the misoprostol group at the dose used, but were not clinically troublesome, the researchers noted. “Most of the trials that have found often upsetting shivering were with 600 mcg, and our study was with 400 mcg,” Dr. Baskett said in an interview.

The study was conducted to substantiate that it is reasonable to use the 400-mcg dose if the local circumstances and resources dictate that it be used, he noted.

UNIVERSAL CITY, CALIF. — A significant number of successful deliveries have occurred, and one patient has delivered two babies, following laparoscopic cervicoisthmic cerclage performed during pregnancy at the University of Illinois, Chicago.

Andrew I. Brill, M.D., professor of ob.gyn. and director of gynecologic endoscopy at the university, reported on more than a dozen cases at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The innovative laparoscopic procedure could offer hope of a minimally invasive alternative to a technically demanding and often complicated abdominal surgery during pregnancy, in patients for whom conventional vaginal cerclage has failed or is not possible.

“These are patients who are quite desperate, with a history of multiple losses despite repeated conventional procedures,” Dr. Brill said.

All the patients in his series had experienced failure of conventional vaginal cerclages for cervical incompetence, and many had suffered repeated second-trimester losses. In some patients, previous cervical procedures precluded placement of a vaginal cerclage.

If such patients desire children, “There really is no salvation but abdominal cervicoisthmic cerclage,” he explained.

Conventional abdominal cerclage typically requires an extended midline abdominal incision and a considerable hospital stay. Complications can include hemorrhage and pregnancy loss. Laparoscopic cervicoisthmic cerclage during pregnancy is a novel and technically challenging procedure. Ideally, it should be performed by 12 weeks' gestation, at a point when the risk of spontaneous first trimester loss is minimal but there is still enough space to safely manipulate and work around the gravid uterus, according to Dr. Brill.

Besides the threat of fetal loss, the risk of bleeding is considerable, so the surgical team must be prepared to quickly convert to conventional surgery. Morbid obesity and the risk of significant abdominal adhesions should be viewed with caution, according to Dr. Brill.

“This is a surgery where you know that if you make a mistake, it's over, and it's a very rapid over,” he said.

Nonetheless, the University of Illinois experience has been largely successful. Dr. Brill noted that the exact numbers are being compiled for publication but that at least 10 healthy babies have been born following the procedure.

Some patients have undergone the procedure as outpatients, while perinatologists have opted to observe others overnight. Some pregnancies are ongoing.

Fetal viability is carefully assessed before and after the procedure, which initially took about 4 hours but, with experience, has been reduced to about 90 minutes.

Two losses have occurred, one the day following the procedure and one at about 20 weeks' gestation in a patient with recurrent previous losses. In one early case, the laparoscopic procedure was converted to laparotomy to control bleeding when the underside of a harmonic scalpel abrupted a uterine vein. The procedure is performed under general anesthetic.

A cervical cup is placed into the vagina and up to the fornices to aid in lifting the uterus for skeletonization of the uterine vessels and placement of a Mersiline ligature between the uterine vessels and the lower segment at the isthmus.

A port is placed at the umbilicus for the laparoscope. Two right and two left paraumbilical ports are placed high and lateral, and one is placed at the midline suprapubic abutting the mons pubis. Bipolar dissection and sharp dissection are used to mobilize the uterine arteries well off the lower uterine segment.

Using a right-angle dissector placed through the suprapubic port, a Mersilene stitch is pulled from back to front through windows created in the broad ligament and tied snugly around the isthmus of the uterus, insuring the suture remains flat against the posterior lower segment.

Throughout the procedure, precautions are taken against over-manipulating the uterus or causing vascular injury. Cutting is performed with monopolar energy or blunt-tipped mechanical scissors.

The uterine vessels are skeletonized and isolated from the lower uterine segment.

The knotted Mersilene stitch has been placed, and the procedure is completed. Photos courtesy Dr. Andrew I. Brill

UNIVERSAL CITY, CALIF. — A significant number of successful deliveries have occurred, and one patient has delivered two babies, following laparoscopic cervicoisthmic cerclage performed during pregnancy at the University of Illinois, Chicago.

Andrew I. Brill, M.D., professor of ob.gyn. and director of gynecologic endoscopy at the university, reported on more than a dozen cases at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The innovative laparoscopic procedure could offer hope of a minimally invasive alternative to a technically demanding and often complicated abdominal surgery during pregnancy, in patients for whom conventional vaginal cerclage has failed or is not possible.

“These are patients who are quite desperate, with a history of multiple losses despite repeated conventional procedures,” Dr. Brill said.

All the patients in his series had experienced failure of conventional vaginal cerclages for cervical incompetence, and many had suffered repeated second-trimester losses. In some patients, previous cervical procedures precluded placement of a vaginal cerclage.

If such patients desire children, “There really is no salvation but abdominal cervicoisthmic cerclage,” he explained.

Conventional abdominal cerclage typically requires an extended midline abdominal incision and a considerable hospital stay. Complications can include hemorrhage and pregnancy loss. Laparoscopic cervicoisthmic cerclage during pregnancy is a novel and technically challenging procedure. Ideally, it should be performed by 12 weeks' gestation, at a point when the risk of spontaneous first trimester loss is minimal but there is still enough space to safely manipulate and work around the gravid uterus, according to Dr. Brill.

Besides the threat of fetal loss, the risk of bleeding is considerable, so the surgical team must be prepared to quickly convert to conventional surgery. Morbid obesity and the risk of significant abdominal adhesions should be viewed with caution, according to Dr. Brill.

“This is a surgery where you know that if you make a mistake, it's over, and it's a very rapid over,” he said.

Nonetheless, the University of Illinois experience has been largely successful. Dr. Brill noted that the exact numbers are being compiled for publication but that at least 10 healthy babies have been born following the procedure.

Some patients have undergone the procedure as outpatients, while perinatologists have opted to observe others overnight. Some pregnancies are ongoing.

Fetal viability is carefully assessed before and after the procedure, which initially took about 4 hours but, with experience, has been reduced to about 90 minutes.

Two losses have occurred, one the day following the procedure and one at about 20 weeks' gestation in a patient with recurrent previous losses. In one early case, the laparoscopic procedure was converted to laparotomy to control bleeding when the underside of a harmonic scalpel abrupted a uterine vein. The procedure is performed under general anesthetic.

A cervical cup is placed into the vagina and up to the fornices to aid in lifting the uterus for skeletonization of the uterine vessels and placement of a Mersiline ligature between the uterine vessels and the lower segment at the isthmus.

A port is placed at the umbilicus for the laparoscope. Two right and two left paraumbilical ports are placed high and lateral, and one is placed at the midline suprapubic abutting the mons pubis. Bipolar dissection and sharp dissection are used to mobilize the uterine arteries well off the lower uterine segment.

Using a right-angle dissector placed through the suprapubic port, a Mersilene stitch is pulled from back to front through windows created in the broad ligament and tied snugly around the isthmus of the uterus, insuring the suture remains flat against the posterior lower segment.

Throughout the procedure, precautions are taken against over-manipulating the uterus or causing vascular injury. Cutting is performed with monopolar energy or blunt-tipped mechanical scissors.

The uterine vessels are skeletonized and isolated from the lower uterine segment.

The knotted Mersilene stitch has been placed, and the procedure is completed. Photos courtesy Dr. Andrew I. Brill

UNIVERSAL CITY, CALIF. — A significant number of successful deliveries have occurred, and one patient has delivered two babies, following laparoscopic cervicoisthmic cerclage performed during pregnancy at the University of Illinois, Chicago.

Andrew I. Brill, M.D., professor of ob.gyn. and director of gynecologic endoscopy at the university, reported on more than a dozen cases at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The innovative laparoscopic procedure could offer hope of a minimally invasive alternative to a technically demanding and often complicated abdominal surgery during pregnancy, in patients for whom conventional vaginal cerclage has failed or is not possible.

“These are patients who are quite desperate, with a history of multiple losses despite repeated conventional procedures,” Dr. Brill said.

All the patients in his series had experienced failure of conventional vaginal cerclages for cervical incompetence, and many had suffered repeated second-trimester losses. In some patients, previous cervical procedures precluded placement of a vaginal cerclage.

If such patients desire children, “There really is no salvation but abdominal cervicoisthmic cerclage,” he explained.

Conventional abdominal cerclage typically requires an extended midline abdominal incision and a considerable hospital stay. Complications can include hemorrhage and pregnancy loss. Laparoscopic cervicoisthmic cerclage during pregnancy is a novel and technically challenging procedure. Ideally, it should be performed by 12 weeks' gestation, at a point when the risk of spontaneous first trimester loss is minimal but there is still enough space to safely manipulate and work around the gravid uterus, according to Dr. Brill.

Besides the threat of fetal loss, the risk of bleeding is considerable, so the surgical team must be prepared to quickly convert to conventional surgery. Morbid obesity and the risk of significant abdominal adhesions should be viewed with caution, according to Dr. Brill.

“This is a surgery where you know that if you make a mistake, it's over, and it's a very rapid over,” he said.

Nonetheless, the University of Illinois experience has been largely successful. Dr. Brill noted that the exact numbers are being compiled for publication but that at least 10 healthy babies have been born following the procedure.

Some patients have undergone the procedure as outpatients, while perinatologists have opted to observe others overnight. Some pregnancies are ongoing.

Fetal viability is carefully assessed before and after the procedure, which initially took about 4 hours but, with experience, has been reduced to about 90 minutes.

Two losses have occurred, one the day following the procedure and one at about 20 weeks' gestation in a patient with recurrent previous losses. In one early case, the laparoscopic procedure was converted to laparotomy to control bleeding when the underside of a harmonic scalpel abrupted a uterine vein. The procedure is performed under general anesthetic.

A cervical cup is placed into the vagina and up to the fornices to aid in lifting the uterus for skeletonization of the uterine vessels and placement of a Mersiline ligature between the uterine vessels and the lower segment at the isthmus.

A port is placed at the umbilicus for the laparoscope. Two right and two left paraumbilical ports are placed high and lateral, and one is placed at the midline suprapubic abutting the mons pubis. Bipolar dissection and sharp dissection are used to mobilize the uterine arteries well off the lower uterine segment.

Using a right-angle dissector placed through the suprapubic port, a Mersilene stitch is pulled from back to front through windows created in the broad ligament and tied snugly around the isthmus of the uterus, insuring the suture remains flat against the posterior lower segment.

Throughout the procedure, precautions are taken against over-manipulating the uterus or causing vascular injury. Cutting is performed with monopolar energy or blunt-tipped mechanical scissors.

The uterine vessels are skeletonized and isolated from the lower uterine segment.

The knotted Mersilene stitch has been placed, and the procedure is completed. Photos courtesy Dr. Andrew I. Brill

ST. PETE BEACH, FLA. — Take time to focus specifically on wine consumption when routinely questioning pregnant patients about their use of alcohol.

That was the message in a poster on a study of alcohol consumption during pregnancy presented at the annual meeting of the Teratology Society.

The prospective, clinic-based cohort study involved 4,494 women interviewed at their first prenatal visit. Of these, 16% reported signs consistent with alcohol abuse and dependence, and half of those reported steady or binge drinking during pregnancy, reported William Rayburn, M.D., of the University of New Mexico, Albuquerque, and his colleagues.

A total of 208 women with signs of alcohol abuse or dependence completed the study, including a 1-month postpartum interview.

Wine was the beverage of choice for about 25% of participants. Those who drank wine tended to consume lower quantities of alcohol, but a high percentage (43%) of wine drinkers continued their wine drinking after becoming aware of their pregnancy. This was particularly true among older white women, who were significantly more likely than younger women and minorities to continue drinking after pregnancy awareness.

Wine is one of the most widely consumed alcoholic beverages among women of reproductive age, including those who are problem drinkers both before and after becoming aware of their pregnancy. Specifically discussing the matter of wine consumption with pregnant patients is worthwhile, the researchers said.

ST. PETE BEACH, FLA. — Take time to focus specifically on wine consumption when routinely questioning pregnant patients about their use of alcohol.

That was the message in a poster on a study of alcohol consumption during pregnancy presented at the annual meeting of the Teratology Society.

The prospective, clinic-based cohort study involved 4,494 women interviewed at their first prenatal visit. Of these, 16% reported signs consistent with alcohol abuse and dependence, and half of those reported steady or binge drinking during pregnancy, reported William Rayburn, M.D., of the University of New Mexico, Albuquerque, and his colleagues.

A total of 208 women with signs of alcohol abuse or dependence completed the study, including a 1-month postpartum interview.

Wine was the beverage of choice for about 25% of participants. Those who drank wine tended to consume lower quantities of alcohol, but a high percentage (43%) of wine drinkers continued their wine drinking after becoming aware of their pregnancy. This was particularly true among older white women, who were significantly more likely than younger women and minorities to continue drinking after pregnancy awareness.

Wine is one of the most widely consumed alcoholic beverages among women of reproductive age, including those who are problem drinkers both before and after becoming aware of their pregnancy. Specifically discussing the matter of wine consumption with pregnant patients is worthwhile, the researchers said.

ST. PETE BEACH, FLA. — Take time to focus specifically on wine consumption when routinely questioning pregnant patients about their use of alcohol.

That was the message in a poster on a study of alcohol consumption during pregnancy presented at the annual meeting of the Teratology Society.

The prospective, clinic-based cohort study involved 4,494 women interviewed at their first prenatal visit. Of these, 16% reported signs consistent with alcohol abuse and dependence, and half of those reported steady or binge drinking during pregnancy, reported William Rayburn, M.D., of the University of New Mexico, Albuquerque, and his colleagues.

A total of 208 women with signs of alcohol abuse or dependence completed the study, including a 1-month postpartum interview.

Wine was the beverage of choice for about 25% of participants. Those who drank wine tended to consume lower quantities of alcohol, but a high percentage (43%) of wine drinkers continued their wine drinking after becoming aware of their pregnancy. This was particularly true among older white women, who were significantly more likely than younger women and minorities to continue drinking after pregnancy awareness.

Wine is one of the most widely consumed alcoholic beverages among women of reproductive age, including those who are problem drinkers both before and after becoming aware of their pregnancy. Specifically discussing the matter of wine consumption with pregnant patients is worthwhile, the researchers said.

Hispanic women and those who receive prenatal care at a hospital or clinic were less likely to be screened for group B streptococcus in North Carolina during 2002–2003, the Centers for Disease Control and Prevention reported.

In 2002, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists jointly recommended universal prenatal screening for vaginal and rectal group B streptococcus (GBS) colonization at 35–37 weeks' gestation. The same year, the CDC began analyzing GBS screening rates in the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based monthly mail/telephone survey of randomly selected women in the state who have recently delivered a live-born infant.

The data comprise responses from 3,027 women who were included in the sample. In 2002, 70% reported having been tested for GBS during their most recent pregnancy, 11% said they had not been tested, and 19% did not know whether they had been tested. In 2003, those proportions were 74%, 8%, and 18%, respectively, the CDC reported (MMWR 2005:54:700–3).

Among the women who knew their GBS status, the factors significantly associated with lack of prenatal screening on multivariate analysis were Hispanic ethnicity, receipt of prenatal care primarily at a hospital clinic or health department (versus private physician/HMO), and lack of prenatal HIV testing. Those same factors also were associated with lack of knowledge of GBS screening on multivariate analysis, along with black race, other race, and Medicaid payment of delivery.

The incidence of invasive perinatal GBS disease in the United States declined 34% from 2002 to 2003, following the universal screening recommendation. Further efforts to reduce disparities in prenatal GBS screening among minority populations will be needed for continued progress, the CDC said.

Hispanic women and those who receive prenatal care at a hospital or clinic were less likely to be screened for group B streptococcus in North Carolina during 2002–2003, the Centers for Disease Control and Prevention reported.

In 2002, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists jointly recommended universal prenatal screening for vaginal and rectal group B streptococcus (GBS) colonization at 35–37 weeks' gestation. The same year, the CDC began analyzing GBS screening rates in the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based monthly mail/telephone survey of randomly selected women in the state who have recently delivered a live-born infant.

The data comprise responses from 3,027 women who were included in the sample. In 2002, 70% reported having been tested for GBS during their most recent pregnancy, 11% said they had not been tested, and 19% did not know whether they had been tested. In 2003, those proportions were 74%, 8%, and 18%, respectively, the CDC reported (MMWR 2005:54:700–3).

Among the women who knew their GBS status, the factors significantly associated with lack of prenatal screening on multivariate analysis were Hispanic ethnicity, receipt of prenatal care primarily at a hospital clinic or health department (versus private physician/HMO), and lack of prenatal HIV testing. Those same factors also were associated with lack of knowledge of GBS screening on multivariate analysis, along with black race, other race, and Medicaid payment of delivery.

The incidence of invasive perinatal GBS disease in the United States declined 34% from 2002 to 2003, following the universal screening recommendation. Further efforts to reduce disparities in prenatal GBS screening among minority populations will be needed for continued progress, the CDC said.

Hispanic women and those who receive prenatal care at a hospital or clinic were less likely to be screened for group B streptococcus in North Carolina during 2002–2003, the Centers for Disease Control and Prevention reported.

In 2002, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists jointly recommended universal prenatal screening for vaginal and rectal group B streptococcus (GBS) colonization at 35–37 weeks' gestation. The same year, the CDC began analyzing GBS screening rates in the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based monthly mail/telephone survey of randomly selected women in the state who have recently delivered a live-born infant.

The data comprise responses from 3,027 women who were included in the sample. In 2002, 70% reported having been tested for GBS during their most recent pregnancy, 11% said they had not been tested, and 19% did not know whether they had been tested. In 2003, those proportions were 74%, 8%, and 18%, respectively, the CDC reported (MMWR 2005:54:700–3).

Among the women who knew their GBS status, the factors significantly associated with lack of prenatal screening on multivariate analysis were Hispanic ethnicity, receipt of prenatal care primarily at a hospital clinic or health department (versus private physician/HMO), and lack of prenatal HIV testing. Those same factors also were associated with lack of knowledge of GBS screening on multivariate analysis, along with black race, other race, and Medicaid payment of delivery.

The incidence of invasive perinatal GBS disease in the United States declined 34% from 2002 to 2003, following the universal screening recommendation. Further efforts to reduce disparities in prenatal GBS screening among minority populations will be needed for continued progress, the CDC said.

Pregnant women and women who think they might become pregnant should avoid the care and feeding of pet rodents and avoid contact with wild rodents to reduce their risk of contracting the lymphocytic choriomeningitis virus from the animals, the Centers for Disease Control and Prevention has advised.

Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to a family member or a professional exterminator. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. Most LCMV infections do not cause serious illness. Symptoms include stiff neck, fever, muscle aches, and nausea.

Although the risk for LCMV infection is fairly low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to CDC.

Observing good hygiene practices and environmental modifications can reduce the risk of infection; the virus has been shown to transfer from rodents to humans, but not from person to person (MMWR 2005;54:747–8).

Pregnant women and women who think they might become pregnant should avoid the care and feeding of pet rodents and avoid contact with wild rodents to reduce their risk of contracting the lymphocytic choriomeningitis virus from the animals, the Centers for Disease Control and Prevention has advised.

Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to a family member or a professional exterminator. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. Most LCMV infections do not cause serious illness. Symptoms include stiff neck, fever, muscle aches, and nausea.

Although the risk for LCMV infection is fairly low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to CDC.

Observing good hygiene practices and environmental modifications can reduce the risk of infection; the virus has been shown to transfer from rodents to humans, but not from person to person (MMWR 2005;54:747–8).

Pregnant women and women who think they might become pregnant should avoid the care and feeding of pet rodents and avoid contact with wild rodents to reduce their risk of contracting the lymphocytic choriomeningitis virus from the animals, the Centers for Disease Control and Prevention has advised.

Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to a family member or a professional exterminator. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. Most LCMV infections do not cause serious illness. Symptoms include stiff neck, fever, muscle aches, and nausea.

Although the risk for LCMV infection is fairly low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to CDC.

Observing good hygiene practices and environmental modifications can reduce the risk of infection; the virus has been shown to transfer from rodents to humans, but not from person to person (MMWR 2005;54:747–8).