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OG SURVEY - OBSTETRICS (with a little bit of gynaecology at the end) AUGUST, SEPTEMBER, OCTOBER, NOVEMBER 2013 (CLUSTERED IN RELATED TOPICS) PERINATAL DEATH AND LOW DOSE ASPIRIN: A META-ANALYSIS (OCTOBER 2013)Roberge S. Ultrasound OG 2013;41:491. 42 prospective RCTs involving over 27,000 at risk pregnant women treated with low dose aspirin ( ≤ 150 mg/ day) versus placebo were reviewed in a meta-analysis. Low dose aspirin commenced ≤ 16 weeks v no aspirin was associated with large reductions in:Perinatal deathRR 0.41 ( Aspirin started > 16w v placebo: RR 0.93)Causes of death included: preeclampsia, abruption, fetal growth restrictionPreeclampsiaRR 0.47( Later aspirin RR 0.78)Severe preeclampsiaRR 0.18( Later aspirin RR 0.65)Fetal growth restrictionRR 0.46( Later aspirin RR 0.98)Preterm birthRR 0.35 ( Later aspirin RR 0.90)Although preeclampsia, abruption, fetal growth restriction and preterm birth do not manifest until much later in pregnancy, it is thought that the underlying processes mostly occur in the late first trimester with inadequate trophoblast invasion and inadequate transformation of the spiral arteries into the low resistance vessels needed to optimise placental development. Aspirin is thought to improve these vascular changes. Since abnormal uterine artery blood flow is apparent on ultrasound at 12 weeks in women who will develop preeclampsia, the authors believe that initiation of aspirin between 8 and 12 weeks is probably ideal. ConclusionLow dose aspirin commenced before 16 weeks improves a range of placenta-related pregnancy outcomes in at risk women while aspirin started after 16 weeks is far less effective. The ideal time to commence aspirin is probably 8 – 12 weeks. PERINATAL – OPTIMISING THE DEFINITION OF IUGR (PORTO Study) (AUGUST 2013)Unterscheider J, AmJOG 2013;208:290.e1-290.e6 The ability to differentiate the healthy constitutionally small baby from the growth restricted baby was investigated in this prospective study at 7 academic obstetric centres in Ireland. Pregnancies where there was ultrasound estimated fetal weight (EFW) below the 10th centile between 24 – 37 weeks were followed with at least fortnightly scans and their perinatal outcomes analysed. The composite adverse perinatal outcome comprised: hypoxia or prematurity-related brain injury, necrotising enterocolitis, bronchopulmonary dysplasia, sepsis and death.The results were:Around 1100 patients with structurally normal fetusus completed the studyMean gestation at enrolment = 30 weeks and at delivery = 38 weeksMean birth weight was 2500g +/- 670 g72% had a normal outcome (no NICU admission, morbidity or death)1 in 4 infants was admitted to the NICU, reflecting the high risk nature of the cohort 1 in 20 (5.2%) infants was affected by the composite adverse perinatal outcome Composite adverse perinatal outcome occurred in:Low EFW EFW < 10th centile 5.2% (58 / 1080) adverse outcomes EFW < 3rd centile6.2%(51 / 826)3 – 10th centile2.0% ( 5 / 254)Low EFW + Abnormal Umbilical Artery DopplerEFW < 10th centile + abn UA11.4% (47 / 413) adverse outcomes EFW < 3rd centile + abn UA16.7%(42 / 209)Irrespective of EFW or abdominal circumference (AC) the strongest and most significant association with adverse perinatal outcome was an abnormal umbilical artery Doppler. EFW < 3rd centile was the only sonographic EFW consistently associated with adverse perinatal outcomeOligohydramnios was only significantly associated with adverse perinatal outcome when combined with EFW < 3rd centile. ConclusionAbnormal UA Doppler and EFW < 3rd centile were strongly and consistently associated with adverse perinatal outcome while other EFW, AC and AFI measurements were not. The authors speculate whether stricter ultrasound cut-offs may be a better use of limited ultrasound resources. BIRTH – PRIMARY CAESAREAN: CONSEQUENCES ACROSS LIFE (AUGUST 2013)Miller E, OG 2013;121:789-97Using mathematical modelling, this study reports that if a woman has a non-labour CS for her first birth and a CS for each subsequent birth, when compared to successive vaginal births, the short term outcomes areFirst birth Maternal risks slightly higher for 1st CS than 1st VBNeonatal risks (birth asphyxia and brachial plexus injury) considerably lower for 1st CS than 1st VBFourth birthMaternal risks 3 x higher for 4th CS than for 4th VBNeonatal risks equivalent for 4th CS and 4th VB ConclusionAs above. BIRTH – PRIMARY CAESAREAN: PLACENTA ACCRETA (AUST) (NOVEMBER 2013)Kamara M, BJOG 2013;120:879.This case-control study from WA examined the association of placenta accreta with the type of primary caesarean section. 65 women with placenta previa complicated by accreta from 1993 – 2008 were compared to 101 controls with placenta previa uncomplicated by accreta.The analysis found that those women who underwent their primary CS without labour were 3x more likely to develop placenta accreta if they had a placenta previa than those who had their primary CS in labour. ConclusionPrimary CS without labour is associated with a 3 x higher risk of placenta accreta should placenta previa develop in a future pregnancy. BIRTH – DEFINING ‘TERM PREGNANCY’ (NIH) (SEPTEMBER 2013)Spong CY. JAMA 2013 May 3 onlineAt a USA Government National Institutes of Health (NIH) workshop, experts decided to divide the 5 week period ‘term’ (37 – 42 weeks) into 3 periods based on perinatal outcomes stating that more precise definitions may influence timing of delivery and improve outcomes for women and children:The new nomenclature periods areEarly term: 370 – 386 weeksFull term390 – 406 weeksLate term410 - 416 weeksThe lowest fetal and neonatal mortalities and morbidities are in the full term group being slightly higher either side of it. In 2005 a similar decision was made to refer to the period 340 – 366 weeks as ‘late preterm’ rather than ‘near term’ in recognition of the fact that children born at that gestation have measurably poorer school outcomes than those born just a few weeks later. The change in nomenclature has possibly been responsible for the reduction in the rate of iatrogenic late preterm birth in the USA over the past two years. Since babies born at 39 weeks do better than those born at 37 – 38 weeks, it is hoped the linguistic distinction may encourage obstetricians to wait (and help them encourage their patients to wait) until ‘full term’ before induction or CS unless medically indicated. ConclusionThe NIH recommends emphasising the better outcomes experienced by babies born 390 – 406 weeks compared to those born in the weeks just before or just after by changing the nomenclature of the term period. BIRTH – THIRD STAGE: IV TRANEXAMIC ACID AND PPH RATES: AN RCT (OCTOBER 2013)Gungorduk K AmJPerinatol 2013;30:407This RCT from Turkey allocated women (n = 228) to the antifibrinolytic agent tranexamic acid 1g IV in a 30mL glucose solution or 30mL IV glucose alone (n = 226) both administered over 5 minutes at the time of delivery of the anterior fetal shoulder. Standard oxytocic management of the third stage occurred in both groups.The findings wereTranexamic AcidPlaceboBlood loss260 mL350 mLPPH > 500 mL 2% 7%Extra uterotonics needed 3% 9%Blood transfusion rates the same in each group (figures not given in abstract)Day 1 Hb 99g/L 90g/LVomiting 14% 6%Diarrhoea 7% 2% VTE events at 3 week follow up nil nil The above outcomes were significantly different between the two groups except for BTx and VTE. ConclusionTranexamic acid can reduce the average blood loss during the third stage of labour. Determining the clinical situations in which its use may be beneficial is the next research objective. PRETERM BIRTH – ACTIVITY RESTRICTION AND PRETERM BIRTH RATES IN WOMEN WITH SHORT CERVIX (NIH) (NOVEMBER 2013) Grobman WA. OG 2013;121:1181.This is a secondary analysis of a large USA Government NIH funded RCT where asymptomatic nulliparous women with singleton gestations and cervical length < 30mm were randomised to weekly IM 17-a OH progesterone injections or placebo (the original study showed no difference in outcome with 25% delivering < 37 weeks with progesterone and 24% with placebo). Restriction in activity was not part of the study recommendation for either group but was left up to the patient’s obstetrician. During the weekly study visits however, participants were routinely asked if their obstetrician had recommended any form of activity restriction – no sexual intercourse, reduce or stop work, reduce or stop other non-work activities. Activity restriction data was available for 98% of the study participants (about 650 women). Nearly 40% of the women with a short cervix had been advised to restrict some activities and, of this group, two-thirds had been advised to restrict all three activities. The women advised to restrict activities were older and more likely to have private insurance. They also had shorter cervices and were more likely to have funnelling or intra-amniotic debris while there was no significant relationship between activity restriction and treatment with 17a OHP, cervical length < 15mm or gestational age at recruitment. Preterm birth < 37 weeks was significantly more common in women placed on any restriction than those unrestricted (37% v 17%). After controlling for the demographic and ultrasound feature differences between the two groups, preterm birth < 37 weeks and < 34 weeks remained 2.3 x higher in women advised any activity restriction compared to those unrestricted in activity. The results remained the same when only a limitation in work was advised (2.6 x more likely to deliver early). Activity restriction Increases diuresis and reduces plasma volume. Increases VTEIncreases bone loss and muscle deconditioning. Often places women and their families in financial difficulty thereby increasing their stress and anxiety which are known risk factors for preterm birth. It is physiologically plausible therefore that advising women to stop work, stop other activities and avoid sexual intercourse could in fact truly increase their risks of delivering preterm.ConclusionThere has never been any data to support ‘rest’ as a therapy for improvement in any pregnancy outcome including miscarriage, preterm birth and blood pressure control. Obstetricians generally consider it a benign recommendation to make, often a throwaway line in the mix of advice they give to pregnant women. This study shows that such advice to restrict activity may in fact be harmful. PRETERM BIRTH – PPROM – OUTPATIENT CARE v INPATIENT CARE (AUST) (OCT 2013)Beckmann M. ANZJOG 2013;53:119This non-randomised prospective cohort study from the Mater Hospital Brisbane was undertaken to determine the outcomes of women admitted for PPROM < 34 weeks and not delivered within the initial 72 hours. Of the initial 478 women, 151 (just under one-third) were undelivered after 72 hours and 144 women formed the final cohort. Of this 144, 91 had inpatient and 53 had outpatient management. The groups did not differ in demographic characteristics and the median gestation at PPROM was 28 weeks in both groups. The outpatient group had twice weekly review of symptoms, clinical assessment, CTG and FBC/CRP, with formal growth ultrasound every 2 weeks. The inpatient group had daily review of symptoms, clinical assessment and CTG with twice weekly FBC/CRP with formal growth ultrasound fortnightly. There outcomes wereInpatient n = 91Outpatient n = 53Latency after PPROM12 days33 days (sig)Birthweight1600 g2100 g (sig)NICU time33 days20 days (sig)FDIU 9% 4% (NS)NND 1% 6%(NS)All other outcomes – neonatal and maternal - were the same in both groups ConclusionAlthough the groups were not randomised, the data suggest that there is no disadvantage in managing appropriate women with PPROM at home rather than in hospital and that, in fact, there may be significant prolongation of gestation and improvement in birth weight by doing so.PRETERM BIRTH – MATERNAL OBESITY AND PRETERM BIRTH (NOVEMBER 2013)Cnattingius S. JAMA 2013;309:2362. The Swedish Birth Register for 1992 – 2010 was reviewed (nearly 2 million births). BMI data was correlated with preterm birth outcomes in the following categoriesExtreme preterm birth (22 – 27 weeksVery preterm birth (28 – 31 weeks) Moderate preterm birth (32 – 36 weeks).The findings werePreterm birth rates ≤ 27 weeks occurred inNormal weight women0.17%BMI 25 – 300.21%BMI 30 – 350.27%BMI 35 – 400.35%BMI > 400.52%Medically indicated preterm birth was increased in all gestational categories Spontaneous preterm birth was increased only in the extreme preterm birth categoryPPROM was increased only in the extreme preterm birth categoryConclusionMaternal overweight and obesity during pregnancy are associated with increased risk for preterm birth with the highest risks occurring for births ≤ 27 weeks. Both medically indicated and spontaneous preterm births are increased in this gestational age group. MULTIPLE PREGNANCY – GROWTH DISCORDANCE IN WELL-GROWN TWINS (OCT 2013)Harper LM. AmJOG 2013;208:393.e1 – 393.e5 Twin gestations with ≥ 20% discordance in EFW on ultrasound but with both twins > 10th centile were reviewed and compared to twin pairs without EFW discordance in this study from the USA. Comparing outcomes for EFW discordance > 20% (even though both > 10th centile) with no discordance, the findings were DC twins Preterm delivery < 34 weeks (35% discordant v 26% non-discordant NS)Preterm delivery < 28 weeks (3.2% v 2.8% NS)NICU admission (NS, no figures given in abstract)Stillbirth not increased (0 v 0 NS) Composite adverse neonatal outcome not increased MC twins Preterm delivery < 34 weeks (65% discordant v 26% non-discordant significant)Preterm delivery < 28 weeks (35% v 4% significant)NICU admission (68% v 23% significant)Stillbirth not increased (4.6% v 0.9% NS but strong trend) Composite adverse neonatal outcome not increased ConclusionDiscordant DC twins with EFW > 10th centile are not at increased risk of adverse perinatal outcomes whereas discordant MC twins are. Discordance in DC twins may represent different genetic potential while discordance in MC twins is more likely to represent a pathological process and warrants close surveillance. PREGNANCY OUTCOME – TYPE 1 DIABETES: CTS SC INSULIN PUMP INFUSION v INTERMITTENT INJECTIONS. (OCT 2013) Wender-Ozegowska E. ANZJOG 2013;53:130 This non-randomised retrospective observational study from Poland compared pregnant women with Type 1 diabetes who received 4 or 5 injections of insulin per day (n = 64) with those who were managed using an insulin pump (n = 64) between 2004 - 2009. The insulin pump group had better control with a reduction in both HbA1c and hypoglycaemic episodes. The editor criticises the article because the long-acting insulin used was neutral protamine Hagedorn (NPH) while modern management of Type 1 diabetes is generally utilises long-acting glargine insulin or similar which has no peak, lasts for 24 hours and essentially provides a continuous even release of insulin every hour. It is almost as good as a pump and is known as ‘the poor man’s pump’. It is generally combined with a very fast acting humalog (Lispro) insulin or similar which has such quick onset it can be given immediately before eating compared with older fast acting insulins which had to be administered 30 minutes before eating. ConclusionInsulin pump provides superior BSL control compared to older regimens of intermittent insulin. CHILD OUTCOME – RAMADAN AND SMALL STATURE IN ADULTHOOD (SEPTEMBER 2013)Reyn JG. Am J Epidem 2013;177:729. This is another study on the impact of in utero experience and later health and disease. Adult Indonesians were weighed and measured and this data then correlated with whether their in utero period coincided with Ramadan, a time when their mothers would have fasted during the day. The control group were those whose in utero period did not coincide with Ramadan. Those exposed to Ramadan were slightly shorter (0.2cm not significant) and slightly thinner (0.32 units of BMI which was significant). A number of studies of children born during or just after famine periods and the resultant longer term health impacts have been published in recent decades. Not only are such children born malnourished, but the longer term health effects of fetal programming appear to be most disadvantageous to those later exposed to a Western diet. Once recent study examined the effect of the Chinese famine of the 1950s and 1960s. Those who were fetuses during that time who were later exposed to a Western diet developed metabolic syndrome at the rate of 36% compared to only 5% in those who were not fetuses during the famine. ConclusionUndernutrition in utero can have lifelong effects especially when combined with overnutrition after birth. TERATOGENESIS – VALPROATE AND AUTISM (SEPTEMBER 2013)Christensen J JAMA 2013;309:1696Valproate (Epilim) is a major teratogen in the first trimester, associated with a 10% chance of birth defects including a 10 x increase in spina bifida. If taken in later pregnancy it causes a significant decline in a child’s IQ compared to other antiepileptic drugs. It is therefore a drug that should be avoided in pregnancy if at all possible. Now there is evidence from the Danish national register for children born 1996 - 2006 that valproate is associated with an approximately 4 x increase in autism in offspring (1% 4% rate of autism). Since valproate is used not only for epilepsy but also for neurogenic pain, bipolar disorder and migraine prophylaxis, it is commonly prescribed to reproductive age women. Since many pregnancies are unplanned and since the listed medical conditions can often be managed by other medications, reproductive age women should only be prescribed valproate if there is no suitable alternative. Women on valproate should be very strongly counselled to avoid conceiving while taking it. ConclusionValproate is not only a major teratogen which also significantly reduces a child’s IQ when taken by the mother during pregnancy, there is also evidence that it is associated with a 4 x increase in autism rates in offspring. INFECTION – PREVENTING INFANT PERTUSSIS (WHOOPING COUGH) (SEPTEMBER 2013)Terranella A. Pediatrics 2013;131:e1748 – e1756Pertussis is currently very prevalent and in 2012, the USA saw more cases than in any year since 1955. There were 18 deaths, most being in babies under 3 months old. Prevention of morbidity and mortality from pertussis (whooping cough) is challenging as 80% are infected from household contacts. Infants younger than 2 months are especially vulnerable as they are too young to be vaccinated. As such, they are responsible for 60% of all infant hospitalisations and 85% of all deaths due to pertussis. The USA Government Centres for Disease Control (CDC) looked at three models to reduce the rates of infection in infants.Vaccinate pregnant women in T2 or T3. This allows antibody passage to fetus in addition to ensuring the mother is not a vector for infection. Vaccinate women immediately postpartumVaccinate women immediately postpartum and vaccinate partner and other close contacts before birth (cocooning strategy). Compared with no vaccination T2 / T3 vaccination33% reduction in infant pertussis cases38% reduction in infant hospitalisations49% reduction in infant deathsPostpartum vaccination plus cocooning33% reduction in infant pertussis cases32% reduction in infant hospitalisations29% reduction in infant deaths Postpartum vaccination alone20% reduction in infant pertussis casessmall reduction in hospitalisation and deaths In addition, T2/T3 vaccination was more cost effective since no other family members other than the pregnant woman needed to be vaccinated. ConclusionT2 / T3 vaccination of pregnant women against pertussis greatly reduces infant infections and deaths and appears to be cost effective. INFECTION – SUSPECTED APPENDICITIS IN PREG – ADV OF MRI (SEPTEMBER 2013)Rapp EJ. Radiology 2013;267:137Acute appendicitis is the most common non-obstetric condition requiring surgery in pregnant women. Diagnosis is more difficult and there is a higher threshold for surgery (we don’t want to operate unnecessarily). At the same time, delay in diagnosis results in higher perforation rates. Is there a way to lower both the false negative surgical rate and the perforation rate? Optimal imaging may be the answer. In terms of diagnosis, varying studies in pregnancy have revealed the following results : Imaging Accuracy:SensitivitySpecificityMRI90%97%Spiral CT (low radiation)90%90%Ultrasound80%80%ConclusionIf available, MRI is probably the imaging tool of choice for diagnosing appendicitis in pregnancy. INFECTION – Group B STREP (GBS) RAPID DETECTION IN LABOUR (NOVEMBER 2013) Abdelazim IA. ANZJOG 2013;53:236.Research from over a decade ago showed that, of women GBS swabbed at 35 – 37 weeks, 12% of the positives were negative in labour a month later while 4% of the negatives were now positive. These limitations have led investigators to seek rapid tests performed in labour and a variety of PCR tests are available (including the one we use at Westmead for TermPROM women). The PCR test result in the current study was available in just under 90 minutes. Approximately 450 women were tested. Using the culture collected in labour as the gold standard, the findings werePCR in labour detected 98.3% of those GBS positive by culture in labour (only 1.7% false negatives)Antenatal culture a month before identified only 73% of those GBS positive by culture in labour giving 27% false negativesPCR in labour had a specificity of 99% giving only 1% false positive resultAntenatal culture a month before had a specificity of 95.5% giving 4.5% false positive resultsThe standard of care is that a GBS positive woman receives appropriate antibiotics at least 4 hours before her baby is born. Antenatal results facilitate immediate antibiotic commencement in labour while PCR testing involves a delay. On the other hand, relying on antenatal culture results from a month previously means that we are both undertreating and overtreating for GBS.A rapid intrapartum test that gives an immediate result is what is needed now. ConclusionFluctuations in GBS colonisation are the norm. As a result, GBS tests collected a month prior to labour do not accurately reflect GBS colonisation on the day of labour. PCR tests much more accurately reflect true GBS colonisation on the day of birth but they currently involve a delay of at least 90 minutes in obtaining the result. An immediate bedside test is needed (and several are being investigated). GENETICS: CARRIER FREQUENCIES RE ABNORMAL GENES (AUGUST 2013)Lazarin GA, Genet Med 2013;15:178-186. This is a large USA cohort report of the results of over 23,000 adults (75% female, 25% male, median age 33 years) who underwent screening for a range of heritable genetic conditions. They were couples and individuals at risk of conceiving children affected by genetic disease (usually autosomal recessive conditions). They underwent DNA assessment via expanded carrier screening panels that permit assessment of hundreds of causal mutations for genetic diseases. Mild conditions were excluded from analysis (the commonest mild condition was MTHFR mutation)The findings were 24% were heterozygous (carriers) for non-mild conditions 5% were carriers for 2 or more non-mild conditionsBy race re being a carrier of a non-mild condition: 44% of tested Ashkenazi Jews were carriers (the highest rate) 9% of tested Asians were carriers (the lowest rate) Out of the > 23,000 samples, homozygous or double heterozygous states were found for the following conditionsAlpha-1 antitrypsin deficiency38 Usually a mild condition, not one for which we would test for antenatally or offer TOPCystic fibrosis 9The results included many CF mutations not usually tested for as they are associated with mild, atypical CF - which is why these homozygotes were unrecognised clinicallyGJB2-related nonsyndromic hearing loss6Factor XI deficiency5Gaucher disease4Familial mediterranean fever312 other disorders had 1 or 2 people identified as carriersIt is now possible to test for thousands of different genetic conditions both with respect to possible reproductive risks and to increased risk of disease and mortality from various conditions. However, with more experience and a more nuanced understanding of the interactions between genes, genetic regulatory mechanisms, and other factors that influence human health and development, it is increasingly evident that a clear and consistent relationship between one specific gene mutation and a predictable phenotype is the exception rather that the rule. It is for this reason that the American College of Obstetricians and the American College of Medical Geneticists continue to limit the number of disorders for which population-based screening is recommended. While DNA testing is increasingly cheap, it generates enormous flow on costs when a condition of uncertain but probably nil or mild consequences is identified by untargeted testing. What are the implications of the condition? Does the partner need testing? Is CVS needed? Is TOP warranted? The same applies to genetic testing for adults re their own risk of future disease. An increased propensity to a number of conditions will be identified in all of us, many of which will never develop or will develop in our 80s but which, in the meantime, will generate considerable anxiety and further expensive investigations and may even prompt us to take medications that may never have been needed. In addition, many hours of medical counselling by GPs and obstetricians are needed. Even then, the implications of many rare, unpredictable or usually mild conditions may not be definable leaving patients confused, anxious and uncertain of what steps to take. ConclusionWhile an abundance of DNA screens are now available, medical practitioners should only order genetic tests they understand the implications of and can adequately counsel patients about. GENETICS: MTR GENE VARIANTS AND RISK OF TRISOMY 21 (AUGUST 2013)Wu X, Eur JOGRepBiol 2013;167:154-9Trisomy 21 is mainly due to abnormal chromosome segregation during meiosis but the exact mechanism of the nondisjunction is unclear. Chronic folate deficiency results in abnormal DNA methylation, DNA strand breaks and aberrant chromosome aggregation. Consequently there is interest in the possible relationship between maternal folate deficiency and fetal trisomy. The methyltetrahydrofolatefolate reductase (MTHFR or MTR) gene encodes for a key enzyme in folate metabolism. It is therefore hypothesised that women carrying a mutation in the MTR gene may have an increased risk of carrying a T21 infant. This meta-analysis was undertaken to review the published literature regarding the two commonest MTR mutations C677T and A1298C and trisomy 21. The findings were:An increased risk (OR 1.3) of having a trisomy 21 fetus in women with the C677T mutationNo increased risk for trisomy 21 with the A1298C MTR mutationPrevious studies have not consistently shown folate supplementation to reduce rates of trisomy 21 conceptions, although there is some evidence of a possible reduction in older mothers. ConclusionThis analysis supports the hypothesis that women carrying the C677T MTR mutation have an increased risk of trisomy 21 offspring. What this may mean for reducing trisomy 21 conceptions is not yet clear. GENETIC VARIANTS IN PRE-ECLAMPSIA: A META-ANALYSIS (SEPTEMBER 2013)Buurma AJ. Hum Reprod Update 2013;19:289 In this meta-analysis of the literature 7 gene variants appear to be significantly associated with the development of preeclampsia. Such variants impact on the following systems:Renin-angiotensin Coagulation and fibrinolysisLipid metabolismInflammation. Further studies are needed to investigate the relative contribution of these variants and the mechanisms by which they affect the risk of developing preeclampsiaConclusionAs aboveGENOMIC MEDICINE – IMPLEMENTING IT IN THE CLINIC (SEPTEMBER 2013)Manolio TA Genet Med 2013;15:258This article discusses the slow implementation of genomic medicine into routine clinical practice largely due to the lack of appreciation by physicians, institutions and payers of the potential for genomics to improve patient care. At the same time, a rigorous process of assessment is needed to ensure that implementation is both useful and cost-effective. ConclusionAs above. GYNAE SURGERY – BOWEL PREP BEFORE LAPAROSCOPY: AN RCT (SEPTEMBER 2013)Won H. OG 2013;121:538-546. Bowel prep has largely disappeared from open colorectal surgery since it has been shown to have no impact even on the rate of anastomotic leak while it makes patients feel considerably worse. It is still often used in laparoscopic colorectal surgery and also in complex laparoscopic gynaecological surgery. This RCT from Jason Abbott’s group at Randwick randomised women undergoing operative laparoscopy including deep pelvic endometriosis resection to three groups of pre-operative bowel preparation. Usual fasting only(n = 86)Fasting plus two days on clear fluids(n = 84)Two days on clear fluids plus picoprep(n = 87)In terms of intraoperative surgical view and bowel handling there was < 1 point difference on a 10-point scale between the three groups. More than 80% scored excellent or good and more than 95% scored ‘sufficient’ for surgical view and bowel handling in all three groups. In terms of how patients felt immediately pre-op (pre-op visual analogue score) the results were:Fasting 2 Day Clear Fluids2 Day Fluids + PicoprepHeadache 21121Thirst152531Weakness01725Tiredness-5 815Anxiety121010Discomfort-8 9 7ConclusionBoth a free-fluid diet and a mechanical bowel prep prior to laparoscopic surgery are associated with significantly worse pre-op patient discomfort compared with routine fasting only and they offer little surgical benefit even when deep pelvic resection is required. GYNAE SURGERY – POST OP PAIN ROBOT v CONVENTIONAL LAPAROSCOPY (AUG 2013)El Hachem L. OG 2013;121:547-553. This prospective non-randomised study from New York compared subjective and objective measures of postoperative pain between patients undergoing conventional (n = 52) and robotic (n = 39) laparoscopy over a period in 2011 – 12. Patients in the robotic group were 6 years older and 6 BMI points heavier. The choice for type of surgery was made by the surgeon.The results were Conventional LaparoscopyRobotic LaparoscopyPost-op stay2 days3 daysOn narcotics4 days4.5 daysResume normal activities13 days21 daysConclusionSince the robotic group was more complex than the conventional group it is not possible to draw conclusions regarding pain control and recovery time from this data but it does build on the body of information available to us. GYNAE SURGERY – TVT AND UTI ANTIBIOTIC PROPHYLAXIS (AUG 2013)Jackson D. Female Pelvic Med Reconstr Surg 2013;19:137-144. TVT surgery for stress urinary incontinence is complicated by post-operative UTI in 10 – 35% of women.In this double blind RCT from Texas, women undergoing outpatient placement of TVT were randomised to oral doses of nitrofurantoin 100mg BD (n = 74) or placebo BD (n = 75) for 3 days post-op. Subjects were observed for symptoms and signs of UTI until 6 weeks and at that time were evaluated by MSU. The findings were UTI 18% with peri-operative nitrofurantoin v 32% without it.The advantages of nitrofurantoin are that it is cheap, effective and usually well-tolerated. It should not be used in women with significant renal impairment (creatinine clearance < 50mL/min). Conclusion3 days of therapy with nitrofurantoin 100mg BD resulted in an almost 50% reduction in UTI in women undergoing outpatient TVT. GYNAE SURGERY – OOPHORECTOMY v OVARY CONSERVATION MORTALITY (AUG 2013)Parker WH. OG 2013;121:709-716. The Nurses Health Study is an ongoing prospective cohort study initiated in 1976 and now involving almost 240,000 cumulative participants. In 2009, a study based on Nurses Health Study data revealed that bilateral oophorectomy at the time of hysterectomy was associated with a higher rate of all-cause mortality, a higher rate of coronary heart disease, stroke, lung cancer and total cancers but a lower rate of ovarian and breast cancer. This 2013 study includes longer term follow up and looks at mortality outcomes in more than 30,000 nurses who underwent hysterectomy including 21,000 before the age of 50 years. Approximately half had bilateral oophorectomy and half had ovarian conservation. Maximal length of follow up was 28 years. The findings regarding bilateral oophorectomy were:The mortality (from all causes) of women who had bilateral oophorectomy was significantly increased compared to those whose ovaries were conserved at the time of the hysterectomy (17% v 13%)WhileThere was a reduction in ovarian cancer 4 v 44 in the oophorectomy womenAnd there was a reduction in breast cancer if oophorectomy occurred < 47 yearsNeverthelessAt no age was there any overall reduction in mortality in the oophorectomy groupIn women under the age of 50years at the time of oophorectomy who had never used estrogen therapy the risk of mortality was significantly increasedIn women who had never used estrogen, the number needed to harm from bilateral oophorectomy was All cause deathNNH = 8Coronary heart deathNNH = 33ConclusionBilateral oophorectomy increases mortality in women < 50yo who have never used estrogenBilateral oophorectomy is not associated with increased survival at any ageBilateral oophorectomy at hysterectomy should be reserved for women with:Cancer of the ovary or endometriumSignificant risk of ovarian cancer (eg BRCA 1, 2)Symptomatic ovarian pathology GYNAE SURGERY – AMBULATION AFTER SURGERY: AN RCT (SEPTEMBER 2013)Liebermann M. OG 2013;121:533-7. Using pedometers to measure how many steps a patient took after surgery and before discharge, women were randomised to usual care (n = 77) or goal-enhanced care (n = 69). In the latter group, staff were instructed to actively encourage patients to mobilise although there were no measures in the study to quantify if that happened or not.The results were the same in both groups regarding length of stay (1.7 v 1.55 days, NS) and number of steps taken (80 steps v 87 steps, NS) with about 12% in each group taking no steps before discharge.Patient-identified barriers to mobilisation wereCathetersIV polesPainThe editor comments that when he was a resident, staff were instructed to walk the patient to the nurses station and back on each shift, actively assisting the woman in her post-operative mobilisation. Rather than simply advising her. ConclusionMobilisation after surgery should be actively promoted and supported by staff and barriers to mobilisation should be limited as much as possible. ................
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