Thursday, August 31, 2017

In case you missed it: Here are the top 5 posts this month

Clinical review: Updates on Cesarean Section
A roundup of the latest research on Cesarean Section

ACOG releases Committee Opinion for Prenatal Corticosteroid Therapy for Fetal Maturation
An updated committee opinion from the American College of Obstetricians and Gynecologists (ACOG), was published in the August issue of Obstetrics & Gynecology.

Vaginal cleaning before cesarean delivery significantly reduces infection: A Systematic Review and Meta-analysis.
A simple and inexpensive intervention of vaginal cleaning with an antiseptic solution before cesarean delivery brings down the rate of endometritis note the results of a Systematic Review and Meta-analysis published August 4 in Journal of Obstetrics and Gynecology.

Adjunct Metformin helps reversal of atypical endometrial hyperplasia
Adjunct metformin treatment help reversal of atypical endometrial hyperplasia (AEH) and improves overall survival in endometrial cancer reports the result of a systematic review and meta-analysis published ahead of print in Journal of Gynecologic Oncology.

Society for Maternal-Fetal Medicine (SMFM) issues guidelines for HCV in pregnancy
The Society for Maternal-Fetal Medicine (SMFM) has issued guidelines for screening and management of Hepatitis C infection in pregnancy.  
The guidelines were published ahead of print in American Journal of Obstetrics and Gynecology.

Wednesday, August 30, 2017

ACOG committee update on Immunization in Pregnancy

The American College of Obstetricians and Gynecologists (ACOG) has released updated guidelines for Tetanus, Diphtheria, and Pertussis Vaccination (Tdap) in pregnancy.

The Committee Opinion No. 718 was published in September issue of Journal of Obstetrics and Gynecology.

This update is especially important to reduce pertussis infection in newborn through passive immunization. Infants 3 months and younger face high risk of pertussis infection and the earliest possible shot they can receive is at 6 weeks of age, thereby leaving a window when they are vulnerable for infection from close family itself.

Increasing research and study data available since 2013, have shown that if mother receives Tdap during the late second or early third trimester (with at least 2 weeks from the time of vaccination to delivery), it is   highly effective in protecting the infant against neonatal pertussis.

The recommendations state that:

1) All pregnant women should be vaccinated with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)during each pregnancy between 27–36-weeks-of-gestation period if possible.

2) All pregnant women should be reassured about safety of vaccine during each pregnancy, so that the newborn can be protected against pertussis till he starts with his own vaccination series.

3) All obstetric health care provider should carry the vaccine and administer it to the women during prenatal visits.

4) All family members, caregivers should also be offered the vaccination if not already received. The ideal time for them to receive the vaccine is 2 weeks before the expected arrival of the baby.

5) If not received during pregnancy the women should be vaccinated postpartum, if she has not received Tdap as adolescent, adult or during the previous pregnancy.

6) In certain circumstances, the women can be given the vaccine outside the 27–36 weeks of gestation window like pertussis outbreak in the community or managing a wound.

7) If she receives the vaccine outside the 27–36 weeks of gestation window, she need not be again given a second dose during 27–36 weeks.

Full Text of Committee Opinion

Tuesday, August 29, 2017

New study reassures postmenopausal women about safety of vaginal estrogen.

Postmenopausal women using vaginal estrogen are not at increased risk of cardiovascular disease and cancer reports the result of study published August 14, 2017 in Menopause.

This is another important study conducted using data from Women's Health Initiative(WHI) observational study which tracked the medical history and health habits of 93,676 women nationwide for 8-12 years. The current study recruited 45,663 women between 50-79 years of age, across 40 US clinical centers. These women did not use systematic estrogen and underwent a median follow-up of 7.2 years.

Results of this prospective observational cohort study showed that in women with intact uterus and using vaginal estrogen, the risk of cardiovascular event, pulmonary embolism, stroke, invasive breast cancer, endometrial and colorectal cancer does not exceed the risk faced by non-hormone users.

Women using vaginal estrogen had 32% lower risk of global index event (GIE), defined as time to first occurrence of coronary heart disease (CHD), invasive breast cancer, stroke, pulmonary embolism, hip fracture, colorectal cancer, endometrial cancer, or death from any cause as compared to non-users (GIE adjusted hazard ratio 0.68, 95% confidence interval 0.55-0.86).

Surprisingly, in Hysterectomized women the composite risk of GIE or individual event did not differ much among users and non-users (GIE adjusted hazard ratio 0.94, 95% confidence interval 0.70-1.26).

Based on the results of this trial, US FDA is considering a proposal to revise the warning labels on low dose estrogen packaging to incorporate the safety profile of vaginal estrogen.

Current labels were approved before any evidence was put forth about safety of vaginal estrogen and it may discourage patients from using topical estrogen which are safe and highly effective in treatment of genitourinary symptoms of menopause. 

Different formulations like topical creams, an intravaginal insert, and an intravaginal ring have the same safety and efficacy.

JoAnn Pinkerton, MD, executive director, North American Menopause Society (NAMS), said in a  position statement released by North American Menopause Society on August 17, “These findings should reassure women and their healthcare providers that low-dose vaginal estrogen, which keeps blood levels within the normal postmenopausal range, is effective and safe for postmenopausal women who need relief from only vaginal symptoms,” says Dr. JoAnn Pinkerton, NAMS executive director. “The boxed warnings about the risk of heart disease, stroke, blood clots, and cancer do not apply to these low-dose vaginal therapies. Instead, women who experience bleeding or those with breast cancer should include their healthcare providers and oncologists in deciding about this option.”

Monday, August 28, 2017

Danish Society of Obstetrics and Gynecology recommends against vaginal seeding in Cesarean births
The potential risks associated with practice of vaginal seeding (VS) in Cesarean Delivery outweighs the hypothetical benefits and consequently we do not recommend it at present says the national recommendations released by Danish Society of Obstetrics and Gynaecology at the national meeting on 19 January 2017.

The recommendation along with a commentary was published online 22 AUG 2017 in British Journal of Obstetrics and Gynecology.

“We could not identify any other national or international society that had systematically investigated the clinical approach to VS,” write Thor Haahr, MD, PhD, from the Department of Obstetrics and Gynaecology at the Institute for Clinical Medicine, Aarhus University Hospital, Skejby, Denmark.

The recommendations are aimed at providing fellow obstetricians and midwives with the basic information about VS so that it can be discussed with couples and families opting for it.

The recommendations state that:

Maternity wards should not take part in screening, guiding or encouraging women for Vaginal Seeding.

Vaginal seeding is contraindicated in infants born before 37 weeks, born to mothers who meet national criteria for group B streptococci(GBS) prophylaxis during delivery, situations in which the cesarean section is done to prevent vertical transmission of infection such as—primary vaginal herpes infection, HIV infection with HIV-RNA >50 copies/ml and any other situations in which the VS will cause potential harm to the fetus.

Parents who still wish to perform VS, can do so provided “it does not interfere with or delay other procedures.” They should be informed about insufficient evidence in favor of any potential benefit and should be provided with patient information booklet. They should also be educated about signs of infection in neonates should any infection occurs after the procedure.

Interest in VS sparked after Dominguez-Bello and colleagues published the results of their pilot study in 2016 stating that Neonatal colonization can be partially restored in cesarean born babies by VS.  Several other studies have since followed involving VS which stress the importance of more research and publications on this topic.

Although, the risk associated with VS is very low, the immediate concern after VS is early onset neonatal sepsis (EOS) with Escherichia coli or GBS.

David A. Eschenbach, MD, from the Department of Obstetrics and Gynecology, University of Washington, Seattle raised several questions in his accompanying commentary that need to be addressed before VS becomes a routine practice.

His major concern was our current inability to identify that which vaginal bacteria/gut bacteria will produce potential benefit while minimizing the harm. Choosing between ‘harmful’ and ‘helpful’ bacteria is expensive procedure and it is here the cost -benefit analysis comes in.

"We simply are too far behind in knowledge to start this practice without heeding the Society's recommendations," he concluded.

The authors suggest that clinicians whose patients want to adopt the practice should be told about the risk involved and other ways of that have an effect on neonatal colonization, including early skin-to-skin contact, breast-feeding, and diet during pregnancy.

Sunday, August 27, 2017

Trying to Understand Stillbirths

Stillbirths affects 1% of all pregnancies in US, amounting to nearly 24,000 deaths every year. Recent advances in medicine has brought down the neonatal and infant mortality considerably in last decade, but the decline is still birth rate is very slow.

A lack of understanding of the mechanisms behind it coupled with inability to predict stillbirth has prevented significant improvement in stillbirths’ rate.

Although altered fetal growth and placental abnormalities are strongest predictors of stillbirths but all patients with placental abnormalities do not end up in stillbirths, reflecting our lack of understanding of this interrelationship.

This population based case control study included 613 women who had stillbirths and 1747 women who had live births and who consented to placental pathological examination from 59 hospitals in 5 geographic areas in the U.S.

Study was published online August 18, 2017 in Journal PloS one.
About 15 placental pathologies were most prevalent in women with stillbirths and fetal growth abnormalities.

Out of 15, ten were also associated with fetal growth retardations. These are: single umbilical artery; velamentous insertion; terminal villous immaturity; retroplacental hematoma; parenchymal infarction; intraparenchymal thrombus; avascular villi; placental edema; placental weight; ratio birth weight/placental weight)

The other 5 (acute chorioamnionitis of placental membranes; acute chorioamionitis of chorionic plate; chorionic plate vascular degenerative changes; perivillous, intervillous fibrin, fibrinoid deposition; fetal vascular thrombi in the chorionic plate) resulted in stillbirths without altered fetal growth.  

Terminal villous hypoplasia was equally common in live born and still born fetuses with altered fetal growth.

Maternal factors associated with still births were gestational hypertension/pre-eclampsia (20% versus 11%, p<0.001), hypertension before pregnancy (11% versus 5%, p<0.001), and pregestational diabetes (7% versus 2%, p<0.001)

Fetal factors associated with still births were congenital malformations (13% versus 3%, p<0.001), lower birth weight (median 1,949 versus 3,321 grams, p<0.001), and lower GA (median 33 versus 39 weeks, p<0.001).

The study results suggest that different mechanisms exist for disruption in placental function and the results vary according to timing of gestation. An acute insult results in still births but no fetal growth alterations while a chronic, low level insult results in fetal growth retardation which may end up in still births.

Some of these placental findings can be diagnosed with prenatal ultrasound and pregnancies managed accordingly, Similarly, birth weight to placental weight ratio could be estimated antenatally by ultrasound and those pregnancies with abnormal ratio and at risk of stillbirths could benefit from early  term delivery.

Access the abstract, Full Text.

Thursday, August 24, 2017

Oral Ketorolac found effective in reducing pain during IUD insertion.

courtesy :

Oral Ketorolac administered 40-60 minutes before Intra Uterine Device(IUD) significantly reduces the pain and discomfort associated with the procedure reports the results of small, randomized trial published recently in Journal of Obstetrics and Gynecology Canada.

Although pain tolerance is different across different population, but many times the prospect of a painful procedure scares patients off from getting an IUD inserted.

Ibuprofen and other pain relievers are not effective and a recent trial with injectable pain killers rated the pain at injection site worse than the procedure itself.

This small randomized trial conducted at community hospital in Columbus, Ohio recruited 72 women over a period of 2 years. Eligible women received Ketorolac 20 mg (n = 35) or a placebo (n = 36) 40-60 minutes before insertion.

Demographics and pain ratings for uterine sounding or tenaculum placements were similar between both the study arms.

The patients rated pain on a scale from 0 to 10. Women in the Ketorolac arm reported significant less pain relief score at the time of insertion (4.2 vs. 5.7, P = 0.031), overall pain (3.6 vs. 4.9, P = 0.047), and pain 10 minutes after the procedure (1.1 vs. 2.5, P = 0.007).

The authors concluded that oral ketorolac is significantly effective in reducing the pain associated with IUD insertion.

Wednesday, August 23, 2017

Ob/Gyn Updated : Ethicon launches ProxiSure Suturing Device, improving precision in Minimal Invasive Surgery

Ob/Gyn Updated : Ethicon launches ProxiSure Suturing Device, improving precision in Minimal Invasive Surgery

Ethicon launches ProxiSure Suturing Device, improving precision in Minimal Invasive Surgery

Ethicon, part of the Johnson & Johnson Medical Devices Companies, announced today the U.S. launch of the ProxiSure™ Suturing Device, an advanced laparoscopic suturing device armed with Ethicon endomechanical, suture and curved needle technologies.

ProxiSure Suturing Device boasts wrist-like maneuverability and curved needle suitable for operating in tight spaces giving surgeons confidence similar to open surgeries. The suturing precision and ease is achieved because surgeons can reach the desired angle, control bites and and secure knots, with having maximum control of the needle during suturing and knot tying all along.

Dr. Niels-Derrek Schmitz, Franchise Medical Director for Ethicon said, "With the patient's health at the forefront of our thinking, we aimed to introduce a suturing device that will help reduce the margin of error in minimally-invasive surgery. Surgeons will now be able to have the same confidence in laparoscopic suturing that they have always had with traditional procedures using Ethicon products."

"Versatility is the key," said Dr. Schmitz. "ProxiSure enables surgeons to do a wide range of tasks in the OR while maintaining an immensely user-friendly configuration." 

ProxiSure Suturing Device is suitable for use in gynecological procedures, bariatric, general and colorectal surgeries, enabling the surgeon to suture a variety of tissue layers, including flat surfaces.

                                    PROXISURE™ Suturing Device In-Service

Media Courtesy: Ethicon.

Tuesday, August 22, 2017

Johnson & Johnson to pay $417 million to a ovarian cancer patient: a blockbuster verdict by Jury

In a landmark decision, a jury has ordered Johnson & Johnson (J&J) to pay $417m (£323m) to a woman who claimed she developed ovarian cancer after using the company’s talc-based products such as Johnson’s Baby Powder for feminine hygiene.

The verdict was given in favor of California resident Eva Echeverria,who claimed that she developed terminal cancer after decades of use of J&J’s products.

This is the largest payout yet with J&J facing thousands of lawsuits (4800) for failure to warn the consumer about cancer risk of its talc based products.

“We are grateful for the jury’s verdict on this matter and that Eva Echeverria was able to have her day in court,” said Mark Robinson, her lawyer, in a statement.

Her lawyers argued that the company continued to market and encourage women to use its talc based products, despite aware of its carcinogenic potential.

Earlier, a Missouri jury has awarded $72 million to the family of an Alabama woman who died from ovarian cancer in October 2015.

Despite being named as baby powder, it is used by millions of adults in sensitive area to prevent  chafing or promote dryness.

In its natural form talc contains asbestos, a proven carcinogenic since decades.American Cancer Society states,” When talking about whether or not talcum powder is linked to cancer, it is important to distinguish between talc that contains asbestos and talc that is asbestos-free. Talc that has asbestos is generally accepted as being able to cause cancer if it is inhaled. This type of talc is not used in modern consumer products. The evidence about asbestos-free talc, which is still widely used, is less clear.”

It is postulated that if talc or a product containing talc is applied to your genital area in any way (whether it’s applied directly — what’s called perineal talc use —  or whether it makes its way there via pads, condoms, etc.), the powder particles might be able to travel from your vagina all the way up to your ovaries.

This may set off inflammation, which is believed to play an important role in etiology for ovarian cancer.

Many studies have looked into possible link between talc use and ovarian cancer, but the findings are equivocal. A 2003 meta-analysis of 16 studies (11,933 patients) found a link between talc use and ovarian cancer while a 2014 study of 61,576 women did not find the same link.

Meanwhile J&J said, “We will appeal today’s verdict because we are guided by the science, which supports the safety of Johnson’s baby powder.”

So, the bottom line is we still do not have sufficient evidence to prove causation. FDA states that, “There is not sufficient evidence to prove a possible connection.” However, after a flurry of recent lawsuits The U.S. FDA Office of Women's Health has agreed to fund a study investigating the possible link between cosmetic talc use and ovarian cancer.

A posting on the FDA's website notes that while women are commonly known to use products containing talc for hygiene and cosmetic purposes, talc's effects on the tissues that make up the female genital system have not been adequately investigated.

Till causation is proved, the consumers are advised to play it safe and can use talc free powders. A lot of companies make talc-free baby powder out of cornstarch, including Johnson & Johnson.

Monday, August 21, 2017

Are you dense? What every woman and her healthcare provider needs to know.

courtesy: Are you dense

Nearly 20 plus years of research have provided sufficient evidence to link dense breast tissue and increased risk of missing cancer diagnosis by screening mammography. As the breast density increases, the reliability of mammogram as a screening tool for picking up breast malignancy decreases.

What is meant by “being dense”? Breast density does not correlate with physically palpated firmness of breast, it is a radiologic finding and cannot be predicted without obtaining a mammogram. 

Mammographic breast density is defined as the relative amount of radio-opaque (white) elements to radiolucent (black) fat on the image. Increase in the proportion of radio-opaque elements leads to greater mammographic breast density.

Radiologists find it difficult to distinguish between tumor and normal dense tissue, both of which appear white on a mammogram.

In fact, mammography will only detect 30% cancer in dense breasts and 80% in non-dense breasts.
Nearly 40% of women have dense breast, which means that only using mammography as a screening tool puts this population at high risk of missing the diagnosis, delayed diagnosis or diagnosis at very late stage of disease. A recent search of PubMed revealed nearly 3,027 studies on masking risk of dense breast tissue.

Increased density of breast is a casual as well as masking risk factor for breast cancer. According to the American Cancer Society, having heterogeneously or extremely dense breast tissue puts you at risk of breast cancer that is equivalent having one first-degree relative with breast cancer. (2.1 to 4 times the normal risk)

Also, women with dense breast are put at increased risk of developing contralateral breast cancer and interval cancer (cancer detected within 12 months of a normal mammogram)

A recent Breast Cancer Surveillance Consortium study noted that breast density exceeds all other risk factors like obesity, family history and delayed childbirth.

About 28 states in USA have passed law regarding the mandatory reporting of breast density and the necessary follow up thereafter, after women have a screening mammogram.

So, is there a standard protocol for supplemental screening if a woman is diagnosed of having dense breast on screening mammogram? No, unfortunately not, the medical community has not agreed on a protocol regarding supplemental screening for women with dense breasts.

In a position statement, the ACOG, identifies dense breast as a moderate risk factor but does not support routine use of adjunct screening modalities in an average risk woman with dense breast. The American Cancer Society urges the patients with dense breast to talk to healthcare providers about additional screening modalities and advises an MRI along with her yearly mammogram in a high-risk group.

The American College of Radiology identifies breast density as a controversial risk factor for breast cancer with no consensus that it confers sufficient risk to warrant supplemental screening.

At this time, it is highly suggested that patient should initiate a dialogue with her physician, regarding the protocol to be followed after the diagnosis of dense breast. Each patient should be individually evaluated about her risk of breast cancer based on her genetics, family history and other risk factors.

One suggested approach based on a paper presented by Lee C. at Society of Breast Imaging/American College of Radiology Breast Imaging Symposium; April 26, 2015; Orlando, FL is to use tomosynthesis for all levels of risk, supplemental whole-breast ultrasonography for women with average risk, and supplemental magnetic resonance imaging for women with intermediate and high risk

For women who are at high risk and also have a contraindication to magnetic resonance imaging, whole breast ultrasonography or molecular breast imaging, if available, may be an appropriate alternative.


The current options available in addition to screening mammography are Tomosynthesis or 3D mammography, Ultrasound, Magnetic Resonance Imaging (MRI), Molecular Breast Imaging (MBI) or Breast Specific Gamma Imaging (BSGI) and Contrast Enhanced Spectral Mammography (CESM)

Nancy M. Cappello, Ph.D. has founded Are You Dense, Inc., and Are You Dense Advocacy, Inc., to educate women and general public about the challenges women with dense breast face regarding the screening tools for detecting early breast cancer.

Classification of Breast Density: American College of  Radiology. 

click to enlarge

Sunday, August 20, 2017

Clinical review: Updates on Menopause

Here is a roundup of the latest research on Menoapuse.

In this article:

Early menopause ups the risk of developing type 2 diabetes
Women who have an early natural menopause have 2.5 times the risk of developing type 2 diabetes as compared to women who have normal menopause reports the results of a large population based study published online July 18, 2017 in Journal Diabetologia.

Oophorectomy during premenopausal hysterectomy: Evaluating the prevalence
Nearly 1 in 3 women undergo oophorectomy during premenopausal hysterectomy in absence of appropriate indication, reports a study published ahead of print May 8, 2017 in North American Menopausal Society (NAMS) journal Menopause.

Loss of estrogen in postmenopausal women puts them at high risk for lumbar disc degeneration.
Declining estrogen levels during perimenopausal and menopausal years is associated with severe lumbar disc degeneration reports a study published online June 12, 2017 in journal Menopause, the journal of The North American Menopause Society (NAMS).

ACP updates guideline for treating Osteoporosis.
According to International Osteoporotic Foundation (IOF), 1 in 3 women over age 50 will experience osteoporotic fractures and nearly 200 million women suffer from osteoporosis worldwide.

Polycystic ovarian syndrome increases the risk of subsequent early ovarian aging later in life.
Women with polycystic ovarian syndrome (PCOS) have 8.64-fold increase in risk of developing premature ovarian failure as compared to women who did not have PCOS according to a population based study in forthcoming issue of Journal Menopause. Metformin was found to be effective in reducing such risk.

New natural (bioidentical) 17ß-estradiol-progesterone combination available as single soft gel capsules effective in treating postmenopausal symptoms: News from ENDO17
An innovative, investigational combination of 17ß-estradiol and progesterone in a single, oral softgel, was found effective for the treatment of moderate to severe vasomotor symptoms (VMS) due to menopause. The results of the study were presented at the ENDO 2017, the annual meeting of the Endocrine Society in Orlando, Florida, April 1-4.
New class of drug effective in targeting menopausal symptoms: News from Endocrine Conference 2017.
A new class of drug Neurokinin 3 (NK3) receptor antagonists is highly effective and low risk alternative to hormone replacement therapy(HRT) for treatment of menopausal hot flashes according to a study presented at the ENDO 2017, The endocrine society annual meeting from April 1–4, 2017, in Orlando, FL.

Menarche ≤11 years and Nulliparity is a risk factor for Premature and Early Menopause.
Women who had their first period at or before the age of 11 are at increased risk for premature and early menopause and the risk is further amplified if the woman is nulliparous according to a large observational study published on January 25, 2017 in Oxford Journal of Human Reproduction.

Saturday, August 19, 2017

North American Menopause Society (NAMS) video series about important midlife health topics: Midlife Immunizations

The North American Menopause Society (NAMS) has started comprehensive video series for clinicians about important midlife health topics. All the interviews in the series are hosted by NAMS Board of Trustees Member and President Dr. Marla Shapiro, a Canadian physician, who led this exciting initiative.

In this latest video, Midlife Immunizations, Dr. Shapiro interviews Dr. Lisa Larkin, an internist, President of Lisa Larkin MD and Associates, and Director of Women’s Corporate Health at TriHealth in Cincinnati, Ohio.

 Immunizations are critically important to health and wellness of all humane beings, especially midlife women who are often under vaccinated. Women are busy taking care of family members and often neglect their own health, missing to talk with the healthcare provider about their own vaccinations.

This video talk lists why women should take care of their immunization and why these shots play an important role in preventive medicine not only for them but for entire family.

Here is the video about midlife immunizations and why they are important to our health. 

Friday, August 18, 2017

External Cephalic Version for breech presenting fetus does not hike the cesarean section rates.

Women who had a successful External Cephalic Version (ECV) are not at increased risk of cesarean section as compared to women who had Spontaneous Cephalic Version (SCV) says the results of a study published ahead of print on August 2, 2017 in Journal of Obstetrics and Gynecology Canada. 
This is first study conducted to compare the outcome between spontaneous and external version in breech presenting fetuses.

It is estimated that term fetal malpresentation occurs in about 3% of pregnancies—and is a common indication for cesarean. External Cephalic version is an important tool to reduce the rate of cesarean births in breech presentation.

This secondary analysis of Early External Cephalic Version Trial data identified 931 women who had breech presenting fetuses between 34-36 weeks of pregnancy, but cephalic presentation at term.
Out of these study subjects, 557 women have undergone successful ECV while in 374 women the fetus reverted spontaneously.

Obstetric outcomes between the two groups were comparable: 96 women in ECV arm had Cesarean section as compared to 76 in the SCV group. (adjusted OR [aOR] 0.89; 95% CI 0.63-1.26); 393 had vaginal delivery in ECV arm vs 268 in SCV arm. (aOR 0.92; 95% CI 0.68-1.24).

Women in the ECV had 45% increased odds of undergoing instrumental intervention as compared to women in SCV group. (aOR 1.55; 95% CI 0.96-2.50).

Multiparous women with ECV were half as likely to require a cesarean section as compared to women with spontaneous version or no version at all. ( aOR 0.45; 95% CI 0.26-0.80).

The authors concluded, “Women with a cephalic-presenting fetus at birth as a result of successful ECV are not at greater risk of obstetrical interventions at birth when compared with women with fetuses who spontaneously turn to a cephalic presentation in the third trimester.”

Media Courtesy: American Association of Family Physicians 

Thursday, August 17, 2017

HPV testing vs Pap test in cancer screening: Cochrane Systematic review

A negative HPV test is more reassuring than a negative Pap test, as the cytology screening has a higher chance of being false negative thereby missing some women with precancerous lesions and delaying treatment says the result of a Cochrane Systematic review published ahead of print.

Since decades the usual method of screening for cervical cancer is based on cell cytology, but since the etiological relationship between cervical cancer and HPV infection was confirmed along with advent of HPV testing in 1999, the supremacy of these two tests is debated.

Some physician advice Pap and HPV both, especially for women over 30 years old, who are most at risk of cervical cancer, getting both tests provides the best assurance of finding cervical disease before it becomes cancer.

Younger women (20-30) are advised to get HPV test only if their Pap smear looks "inconclusive" or "borderline.”

This systematic review by Cochrane was aimed at determining efficacy of the two tests in detecting precancerous lesions (CIN 2+ and CIN 3+). Literature search for relevant studies till November 2015 identified about 40 studies amounting to a total of 140,000 women between 20 to 70 years old who underwent cervical cancer screening.

Data analysis identified true positives (TP), false positives (FP), true negatives (TN), and false negatives for each screening test (HPV test and cytology) used in each study.

It was seen that HPV test was more sensitive than conventional Pap test and liquid based test in identifying CIN 2+ and CIN 3+, but less specific than Pap test in detecting precancerous lesion.

Data analysis showed that for every 1000 women screened, around 20 women will have precancerous lesions. If HPV test is used, it will correctly identify 16 of the 20 women to be positive for the lesions (but will miss 4 women who have the lesions). The Pap test will correctly identify 12 of the 20 women (but will miss 8 women).

Similarly, for every 1000 women screened, there will be 980 women who will not have precancerous changes. The HPV test will correctly identify 879 women as disease free (but 101 women will be incorrectly told that they have a lesion). The Pap test will correctly identify 951 women (but 29 will be incorrectly told that they have a lesion).

This high false positive rate of HPV testing will lead to high unnecessary referrals and further tests like colposcopy, biopsy and surgery but at the same time it will also identify 50% more women with precancerous changes as compared to conventional cytology.  

The authors concluded that,” Whilst HPV tests are less likely to miss cases of CIN 2+ and CIN 3+, these tests do lead to more unnecessary referrals. However, a negative HPV test is more reassuring than a negative cytological test, as the cytological test has a greater chance of being falsely negative, which could lead to delays in receiving the appropriate treatment.”

Source: Koliopoulos G, Nyaga VN, Santesso N, Bryant A, Martin-Hirsch PP, Mustafa RA, Schünemann H, Paraskevaidis E, Arbyn M. Cytology versus HPV testing for cervical cancer screening in the general population. Cochrane Database Syst Rev. 2017;8:CD008587. doi: 10.1002/14651858.CD008587.pub2. PMID: 28796882

Access the abstract here.

Wednesday, August 16, 2017

ACOG releases Committee Opinion for Prenatal Corticosteroid Therapy for Fetal Maturation

An updated committee opinion from the American College of Obstetricians and Gynecologists (ACOG), was published in the August issue of Obstetrics & Gynecology.

Liggins and Howie published their landmark paper in 1972, that showed the benefits of single course of antenatal corticosteroid therapy administered to women at risk for preterm delivery in reducing RDS and mortality in offspring.

Since then countless trials have confirmed these findings and also shown that timely steroid administration reduces rates of intraventricular hemorrhage (IVH) and necrotizing enterocolitis.

An updated ACOG opinion published in October 2016 issue, expanded the use of steroids in women at high risk for late preterm birth (34 0/7 - 36 6/7 weeks).

The current recommendations are:

A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, irrespective of intact or ruptured membranes and single or multiple gestations.

It could also be given at 23 0/7 weeks of gestation to women at risk of preterm delivery with 7 days based on discussion with family members regarding resuscitation of the newborn.

A decision to administer corticosteroids during the peri viable period (20 0/7 weeks to 25 6/7 weeks of gestation) should always be based on discussions with the patients and family members regarding resuscitation of the newborn.

A single course of betamethasone is recommended for pregnant women at risk of preterm birth between 34 0/7 weeks and 36 6/7 weeks of gestation, provided they have not received a previous course of antenatal corticosteroids.

A single repeat course can be given to women who are less than 34 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, whose previous course was administered more than 14 days earlier and in some clinical scenarios 7 days earlier.

Repeated or serial administration of more than 2 doses is not recommended.

At present, no recommendation can be made for a repeat or rescue dose of corticosteroids in patients with preterm prelabor rupture of membranes (PROM).

ACOG also recommends long term follow up and surveillance of babies who received in utero corticosteroids administration.

It also advocates ongoing development of strategies to support timely administration of corticosteroids to women at risk of delivering with 7 days and avoid overuse in low risk patients.

The committee opinion full text can be accessed here.

Tuesday, August 15, 2017

Finally, a injectable tissue bandage to mend "broken hearts"

The flexible tissue scaffold, shown here emerging from a glass pipette with a tip one millimeter wide

Scientists at University of Toronto have developed an expanding tissue patch that works like a bandage in mending broken hearts. Repairing ischemic heart muscles destroyed by a cardiac event with regenerative stem cells requires an open-heart surgery.

Open-heart surgery is an invasive and risky approach after a heart attack and delivering the regenerative patch through a minimally invasive approach was thought to be impossible.

But now biomedical engineering Professor Milica Radisic (IBBME, ChemE, Toronto General Hospital Research Institute) and her colleagues have developed a technique that lets them use a small needle to inject a repair patch, without the need to open up the chest cavity.

This team is already expert in growing 3D slices of human tissue in laboratory using polymer scaffolds. These tissues are used to test drugs pharmacokinetics in lab.

Professor Milica Radisic says, “If an implant requires open-heart surgery, it’s not going to be widely available to patients,” says Radisic. She says that after a myocardial infarction — a heart attack — the heart’s function is reduced so much that invasive procedures like open-heart surgery usually pose more risks than potential benefits. It’s just too dangerous.”

The researchers have developed a patch that can pass through a narrow needle, and after reaching the target site it still has the memory to spring back to its original shape.

The scaffold is made out of some biodegradable and biocaompatible material that breaks down over time as the stem cells regenerate and form new muscle tissue.

The experiment has already been successful in animal studies and have shown that the patch can improve heart function after myocardial infarction.

The study was Published online 14 August 2017 in Journal of Nature Materials.

 Miles Montgomery, a researcher involved in the study said, “Heart cells are extremely sensitive, so if we can do it with them, we can likely do it with other tissues as well.”

The researchers are working to develop patch for other organs like liver with add-on of growth factor and drugs to be delivered at the site.

It’s a long way before clinical trials are completed and the treatment is available for patients but, a cure for mending “broken hearts” is on the way.

Here is the video to explain how injectable tissue patch could help repair damaged organs.