Here are the top 10 most read posts of 2018

With only a few hours left for the calendar year 2018 to come to an end, take a look at the top 10 most read posts of the year as we gear up to look forward to another year of medical advances and health research. 

ACOG guidance on prevention of surgical-site infection in gynecologic surgery

Surgical site infections (SSIs) after gynecological surgery is a significant cause of postoperative morbidity leading to repeated hospital visits.  These infections also incur heavy social and economic burden on patients and the healthcare system.

The recent ACOG practice bulletin is published in the June issue of Journal of Obstetrics and Gynecology and replaces Practice Bulletin Number 104, May 2009, and Committee Opinion Number 571, September 2013.

https://obgynupdated.blogspot.com/2018/06/acog-guidance-on-prevention-of-surgical.html

New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as a less invasive approach to laparoscopic surgeries. 

NOTES is considered a logical next step in the evolution of minimally invasive surgery, and the first NOTES procedure in humans is often considered to be a transgastric appendectomy performed in India in 2006 which was presented but not reported in manuscript form.

https://obgynupdated.blogspot.com/2018/01/new-approach-to-ovarian-cystectomy.html

Blob and Bagel sign on Ultrasound can be labeled as definitive for Ectopic Pregnancy

Women with the Blob and Bagel ultrasound sign should be reclassified from having ‘probable’ ectopic pregnancy (EP) to ‘definitive’ EP and should be treated as such reports the result of a large retrospective cohort study published March 11, 2018, in Journal of Ultrasound in Obstetrics and Gynecology.

Ectopic Pregnancy is still the leading cause of first-trimester maternal deaths and constitutes 4% of all pregnancy-related deaths. The incidence of ectopic is highest in women undergoing In-Vitro Fertilization (IVF) and ranges from 4% to 11% of all pregnancies.

https://obgynupdated.blogspot.com/2018/03/blob-and-bagel-sign-on-ultrasound-can.html

Novel cross-over sign in cesarean scar pregnancy helps predicts the risk of invasive placentation

First trimester ultrasound scan evaluating the relationship between the gestational sac and the endometrial line in women with cesarean scar pregnancy(CSP) helps predicts the development of abnormally invasive placenta (AIP) and consecutive intra and post-operative surgical morbidities reports the results of a retrospective case series published in the Journal of International Society of Ultrasound in Obstetrics and Gynecology.

Recent advances in prenatal imaging and increase rate of cesarean sections have led to increased diagnosis of CSP. Although, most of the patients with CSP present with severe hemorrhage or rupture uterus, that requires emergency surgical management, few advances further, evolving into AIP. 

https://obgynupdated.blogspot.com/2018/02/novel-cross-over-sign-in-cesarean-scar.html

Negative sliding sign by ultrasound in repeat cesarean section predicts the presence of severe intrabdominal adhesions

A negative sliding sign by ultrasonography (USG) in patients with previous cesarean section helps alert the surgeon to expect massive intraabdominal adhesions, difficult repeat cesarean section and need of blood transfusion during surgery reports the results of a prospective observational study published ahead of print in the February issue of Journal Obstetrics and Gynecology.

Postoperative adhesion formation is quite prevalent after an abdominal or pelvic surgery and any method which can predict the existence of such adhesion could optimize the outcome of current surgery.

https://obgynupdated.blogspot.com/2018/02/negative-sliding-sign-by-ultrasound-in.html

GE Healthcare introduces its new automated breast ultrasound for dense breast

There could not have been a more appropriate time for the launch of GE Healthcare new Invenia Automated Breast Ultrasound (ABUS) 2.0 than October, which is celebrated as breast cancer awareness month. The Invenia ABUS is the only FDA approved 3D ultrasound system for supplemental screening for breast cancer along with mammography.

In conjunction with mammography, it increases the chances of cancer detection in the dense breast by 55%. All breasts are not the same, the density of breast is determined by a proportion of fat and breast tissue—when the percentage of breast tissue exceeds that of fat, breasts are labeled as being dense.

https://obgynupdated.blogspot.com/2018/10/ge-healthcare-introduces-its-new.html

A practical guide to count ovarian antral follicles by ultrasound

A consensus opinion highlighting the main techniques of ovarian antral follicle count (AFC), and providing recommendations for future research is published in the special issue on Reproductive Medicine of the journal Ultrasound in Obstetrics and Gynecology.

The consensus makes several recommendations for varied methods used in counting the antral follicles, but no single method is superior over others and the choice should make the best use of resources available in a setting.

https://obgynupdated.blogspot.com/2018/02/a-practical-guide-to-count-ovarian.html

ACOG update: Letrozole is the first line therapy for ovulation induction in PCOS

The American College of Obstetricians and Gynecologists (ACOG) now recommends Letrozole (aromatase inhibitor) as the first-line treatment for ovulation induction in women with Polycystic Ovarian Syndrome (PCOS) due to data demonstrating increased ovulation rates, clinical pregnancy rates and live-birth rate vs clomiphene citrate. The guidelines are published as Practice Bulletin No. 194 in the June issue of Journal Obstetrics and Gynecology.

This replaces the Practice Bulletin Number 108, published October 2009, which recommends letrozole as first-line therapy for ovulation induction only in women with PCOS and a BMI greater than 30.

https://obgynupdated.blogspot.com/2018/05/acog-update-letrozole-is-first-line-for.html

Sonographically measured fetal head circumference ≥35 cm at term increases the odds of cesarean delivery

Sonographically measured fetal head circumference ≥35 cm, within a week of delivery increases the odds of unplanned cesarean section by 75% report the results of multicenter observational study accepted for publication in American Journal of Obstetrics and Gynecology.

Currently, In the US, one in every third baby is born by cesarean section and the high rate is a cause of concern for the healthcare industry.

https://obgynupdated.blogspot.com/2018/01/sonographically-measured-fetal-head.html

FDA approves a bedside test for assessing the risk of spontaneous preterm birth

QIAGEN won FDA approval for marketing its Novel PartoSure® point of care test for estimating the risk of spontaneous preterm birth in patients who present with symptoms of preterm labor. PartoSure represents a breakthrough in research and development of diagnostic tests for preterm birth.

Predicting preterm birth is a diagnostic challenge and nearly 85% of patients admitted to the hospital for threatened preterm labor (PTL) do not deliver within the next 7 days, resulting in unnecessary interventions.

https://obgynupdated.blogspot.com/2018/04/fda-approves-bedside-test-for-assessing.html

"Does 4 cm dilation constitute active labor?" interview with Dr. Emanuel A. Friedman

Emanuel A. Friedman M.D., of Columbia University, introduced the labor curve, commonly known as “Friedman’s Curve ” to depict the average amount of time it took for a labor patient to dilate each cm. Published nearly 60 years ago, the curve is still followed by a majority healthcare providers to define normal labor.

In 2012, when the National Institute of Child Health and Human Development (NICHD), the Society for Maternal and Fetal Medicine (SMFM), and ACOG held a workshop aimed at “preventing the first Cesarean.” In the workshop, it was discussed that many cesarean sections are simply performed because many women are wrongly categorized as “ failure to progress” based on Friedman’s Curve.

In 2014, ACOG and SMFM issued a consensus statement “Safe Prevention of the PrimaryCesarean Delivery ” to bring down the rising cesarean section rates. The statement redefined normal and abnormal labor and stated that Friedman’s Curve should no longer be used as the basis for modern labor management (ACOG 2014).

A critical study published by Zhang et al. formed the basis of the new guidelines. The study was based on data from the Consortium on Safe Labor and looked at labor records of 62,000 women from 19 hospitals across the U.S. The researchers concluded that “ failure to progress” should be diagnosed at 6 cm and not 4 cm as stated earlier.

ACOG also reaffirmed this statement in 2017 and again in 2018 ACOG Committee Opinion No.766: Approaches to Limit Intervention During Labor and Birth.

Here is an interview with Emanuel A. Friedman about definitions of active and in active labor. He opines that “Woman describes her own labor curve, it is irrelevant to designate a particular point in labor as a demarcation between active and in active labor.”

ACOG updates its recommendations for treatment of Dysmenorrhea and Endometriosis in the Adolescent

The American College of Obstetrics and Gynecology (ACOG) has issued new guidance on diagnosing and relieving dysmenorrhea in adolescents, published in December issue of Journal Obstetrics and Gynecology.

Obstetrician and gynecologists frequently come across adolescents with dysmenorrhea in their practice due to high prevalence ranging between 50% to 90%. It is also responsible for recurrent short-term school absenteeism and reduced quality of life.

Most of the adolescents suffering from dysmenorrhea have primary dysmenorrhea–– painful menstruation in the absence of pelvic pathology.

If the physician suspects it to be primary dysmenorrhea, no pelvic examination or ultrasound is indicated in the initial evaluation. The patient should be put on empirical therapy after a careful history and physical examination.

If the patient does not respond to empirical therapy with NSAIDs and hormonal treatment in 3-6 months, she should be investigated for secondary causes or irregular treatments.

The most common cause of secondary dysmenorrhea is endometriosis, the other being obstructive anomaly of the reproductive tract (hymenal, vaginal, or Mullerian), uterine fibroids and polyps, adenomyosis, cervical stenosis, and adhesions.

Patients who do not respond to treatment for primary dysmenorrhea should be investigated for secondary causes which include pelvic examination and pelvic ultrasound. If pathology is detected, treatment of the cause is warranted.

If no pathology is seen, suspect endometriosis and consider a diagnostic laparoscopy. About 75% of adolescents and young adults with dysmenorrhea who do not respond to NSAIDs and hormonal therapy have endometriosis as the primary pathology. 

Endometriotic lesions present a different appearance in adolescents as compared to a young woman and are typically transparent or red and are challenging to diagnose.   

If a young woman is diagnosed with endometriosis, treatment consists of biopsy of the lesions along with destruction, ablation, or excision of the visible lesions at the time of initial laparoscopy. The patient should also be started on suppressive medical therapy to prevent further endometrial proliferation.

Consideration should be given to placing a levonorgestrel-releasing intrauterine system (LNG-IUS) at the of diagnostic laparoscopy to minimize the pain of insertion later. 

If patients do not respond to conservative surgical therapy and suppressive hormonal therapy, they often benefit from at least six months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.

NSAIDs are the principal medications used for pain relief in endometriosis, and there is no role of long-term opioids in the management of endometriosis, besides being used by a specialized pain management team.

ACOG committee opinion No. 760

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ACOG updates its Recommendations for Well-Woman Care

The American College of Obstetrics and Gynecology (ACOG) recently updated its guidance on well- women care with an emphasis on the vital role an Ob/Gyn plays in maintaining the overall health of women from menarche to menopause and beyond.

The update coincides with the release of ACOG-led Women’s Preventive Services Initiative’s (WPSI) new Well-Woman Chart. The guidance titled “Well Women Visit” was published in the October issue of Obstetrics and Gynecology and replaces the earlier opinion released in August 2012.

The new guidance emphasizes the performance of physical examination (breast and pelvic examination) when indicated by age-group, history or symptoms. The committee also identified the Well-Woman Chart from the WPSI, U.S. Preventive Services Task Force (USPSTF) and Bright Futures, as an important tool to identify the different components of the comprehensive preventive services offered.

Looking at the chart, the Ob/Gyn or other women’s health care providers can prioritize the component for a timely and detailed approach for continuous preventive care throughout the entire lifespan. The Well-Woman Chart provides a list of all the preventive services recommendations for women from the WPSI, US Preventive Services Task Force, and Bright Futures.

The services are advised according to age groups and start at age 13 and end at 75 years with services categorized into general health, infectious disease, and cancer. The chart also has separate services listed for pregnancy and postpartum period.

Much has changed in the last 10 years to shift the focus of patients and practitioner when it comes to yearly well-women visit. The decade has seen a change in the recommendation about the frequency of yearly pap smears, growing popularity of long-acting reversible contraceptive methods and the mandate of performing the pelvic examination in every visit.

The recommendations also recognize that it may not be possible for the patient to complete all the services with one health care provider; hence a team-based approach will facilitate the completion of the services.

The practitioner should begin by a comprehensive medical, family, and reproductive history to individualize physical examination, immunization, and risk assessment. 

The decision to perform a breast and pelvic examination at each visit should be based on detailed family history, reproductive history, and shared decision making. The ACOG recent guidance recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms.

The provider should also counsel the women about essential lifestyle choices and behaviors that have a detrimental effect on women’s’ health like smoking, alcohol, poor diet, and lack of exercise.  These factors also predispose women to high risk for cardiovascular diseases, gynecological cancers, and type 2 diabetes.

All women should be screened for obesity and overweight, and the opportunity should not be lost for counseling the women about maintaining ideal weight and exercising regularly. 

The provider should also discuss with reproductive age women about their reproductive life plan to ensure that all the immunizations are timely complete if planning a pregnancy. Matters like infertility and contraception should also be discussed as appropriate.

The authors further write that discussion about bone health, vulvovaginal symptoms, and sexual health are seldom done during the well-woman visit. The recommendations encourage discussing these issues based on the woman’s phase of life.

In all, an obstetrician and gynecologist should play a crucial role in providing primary and preventive care services to women of all ages.

Christopher Zahn, MD, ACOG vice president of Practice Activities, said in an ACOG news release, “Increasingly, women look to their ob-gyn for both reproductive and primary health care, which creates an exciting opportunity for ob-gyns to build even deeper and longer lasting relationships with our patients,” said Zahn.

“An ob-gyn may care for a patient as an adolescent, through her reproductive years, and as she experiences menopause and beyond. These resources are here to ensure that these ongoing updates to well-woman recommendations are manageable and positive for women’s health care providers and the women who are in their care,” he added further.

Committee opinion

Well-Woman Chart

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Use of alternative antibiotics during C-section increase the odds of wound infection

Use of alternative antibiotics other than the standard recommendation of the first-generation cephalosporin is associated with increased risk of infection and other adverse events, according to a new analysis of more than 6500 cesarean section deliveries. Cephazolin in the drug of choice for surgical prophylaxis in C-section deliveries.

"Use of both standard alternative and inappropriate alternative antibiotics was associated with higher odds of surgical site infections compared with the use of cefazolin for prophylaxis at the time of cesarean delivery," conclude the authors in the study published September 7 in Journal Obstetrics & Gynecology.

The American College of Obstetricians and Gynecologists (ACOG) recommend an infusion of intravenous 1 g cefazolin within 60 min before skin incision. For women with (BMI >30 kg/m 2 or weight > 100 kg, a dose of 2 g cefazolin intravenous infusion is recommended.

In women who are allergic to cephalosporin ACOG recommends alternative antibiotics, such as clindamycin combined with an aminoglycoside.

In this retrospective cohort study conducted over a period of 5 years (2012 – 2017), Tetsuya Kawakita, MD, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC, and colleagues analyzed data from 6584 women who had cesarean delivery in their center.

Majority of women, 6163(93.6%) received standard cefazolin, 274 (4.2%) received the standard alternative, while 147 (2.2%) received inappropriate alternatives— mostly clindamycin or gentamycin.

Propensity score adjusted logistic regression showed that use of alternative antibiotic was not associated with increased risk of the composite primary outcome namely endometritis, cellulitis, deep-wound infection, abdominopelvic abscess, and sepsis. But a subgroup analysis revealed that use of alternative antibiotic increased chances of cellulitis by 93% as compared to use of cephalosporins (adjusted odds ratio [OR], 1.93; 95% CI, 1.03 - 3.31).

Patient receiving alternative antibiotic faced nearly twice the risk of visiting the ER for wound complication (adjusted OR, 2.34; 95% CI, 1.19 - 4.18) compared with cefazolin.

Similarly, use of inappropriate antibiotics increased the odds of primary outcome nearly 4 times as compared to cephazolin (adjusted OR, 4.13; 95% CI, 2.59 - 6.36), while odds of endometritis (adjusted OR, 6.68; 95% CI, 3.69 - 11.44) and cellulitis (adjusted OR, 3.23; 95% CI, 1.63 - 5.81) also increased drastically.

The authors speculated that the difference in sensitivity of skin bacterial flora to the alternative antibiotics might be responsible for increased odds of having cellulitis after the C-section. More studies are warranted on alternate antibiotics other than those recommended by ACOG.

Besides, the authors also stressed that physicians should validate the patients claim of allergy to beta-lactam antibiotics and should not only rely on history given by the patients. They found that only 10-20% of patients documented true allergy on skin testing.

If patients gave a history of nonsignificant beta-lactam allergies, use of cefazolin in such patients might lower the risk of adverse event during cesarean delivery.

Abstract

More on prevention of sepsis during cesarean deliveries:

What is best for Cesarean Antisepsis? Chlorhexidine-Alcohol versus Povidone-Iodine

News from ACOG 2017: Changing gloves before abdominal closure brings down the rate of wound infection by almost 50% in Cesarean Section

Maternal clinical risk factors for the increased rate of post-cesarean infection identified

Use of Monocryl suture minimizes wound complications in cesarean sections - News from SMFM 2017, Las Vegas

Vaginal cleaning before cesarean delivery significantly reduces infection: A Systematic Review and Meta-analysis

ACOG/AHA calls for including a ‘Heart-talk’ during the annual well-woman visit

A joint advisory issued by American College of Obstetrician and Gynecologists (ACOG) and American Heart Association(AHA) calls for all gynecologist to screen women for signs of cardiovascular disease and risk factors during their annual ‘well-woman’ visit.

The presidential advisory published 10 May in Journal Circulation calls for a collaboration between cardiologists and Ob/Gyn physicians to use these visits as an opportunity to screen, counsel and educate women about lifestyle factors that influence the risk of heart diseases.

This is important because, for more than 50% of women, their Ob/Gyn physician is the only primary care doctor they visit every year.

“OB/GYNs are primary care providers for many women, and the annual ‘well woman’ visit provides a powerful opportunity to counsel patients about achieving and maintaining a heart-healthy lifestyle, which is a cornerstone of maintaining heart health” said John Warner, M.D. president of the American Heart Association, executive vice president for Health System Affairs at University of Texas Southwestern Medical Center in Dallas, Texas.

Dr. Stacey Rosen, MD, a cardiologist, co-author of the advisory and vice president of The Katz Institute for Women's Health at Northwell Health said, "We know that 90 percent of women have at least one risk factor for heart disease and that 80 percent of heart disease is preventable through a heart-healthy lifestyle.”

A post-partum visit is an ideal opportunity to identify women with pregnancy complications like pre-eclampsia, eclampsia, chronic hypertension, gestational diabetes, gestational hypertension, pre-term delivery, and low-for-estimated-gestational-age birth weight which all indicate a subsequent increase in the mother’s cardiovascular risk.

Preeclampsia and gestational hypertension impart a three- to six-fold excess risk of subsequent hypertension and a two-fold risk for subsequent heart disease.

In 2001, the Institute of Medicine now the National Academy of Sciences, issued a monograph" Exploring the Biological Contributions to Human Health: Does Sex Matter?" This initiated research on gender-specific risk factors for chronic diseases and development of guidelines that are distinct for men and women based on their unique health risks.

This has considerably helped in bringing down the morbidity and mortality associated with cardiac disease in women in last two decades.

Despite this progress, gender-specific inequalities continue when it comes to managing risk factors for cardiac disease. For example, women who have diabetes are at increased risk of CVD as compared to men (19% vs 10%) but they are far less likely to receive preventive treatment as compared to men.

Similarly, only 29% of older women have a well-controlled blood pressure as compared to 41% of older men.

In women, the CVD risk factors are often related to hormonal or pregnancy influences, such as pregnancy complications and polycystic ovary syndrome, menopausal status and hormone use, but these are seldom considered when calculating the risk of CVD.

Some of the common recommendations in the advisory include:

• All women should be weighed at every visit and diet assessment should be performed through a predetermined questionnaire.
• Women are advised to perform 150 minutes per week of moderate-intensity physical activity, 75 minutes per week of vigorous-intensity aerobic physical activity or a combination of both levels. Women should also walk 10,000 steps per day.
• Presence of behavioral risk factors like smoking and alcohol should be assessed.
• Screening for Glucose intolerance should be done in women 40 to 70 years with obesity or overweight, a history of gestational diabetes, a family history of diabetes or established CVD.
• All women above 20 years of age with a family history of CVD, should undergo lipid screening. Lifestyle modification followed by statins is advised in those with elevated lipids.
• Women with family history of CVD should also be screened for blood pressure every 2 years and annually after 40 years of age.
• Medical therapy would be considered for women without CVD or elevated risk for the disease and with BP measurements greater than 140 mm Hg/90 mm Hg.
• Ob/Gyn and cardiologist should make sure that patients Electronic Health Record (EHR) is complete during each visit and is something does not look good, patients should be referred to a specialist.

The clinicians and patients can visit the following websites to get patient education material.

AHA Life's Simple 7 

AHA's Go Red for Women

ACOG's patient page

Full Text

Ob/Gyn Updated Facebook page

Here is one video from  AHA series ' Life's Simple 7'

ACOG updates its recommendations on Influenza Vaccination During Pregnancy

The American College of Obstetricians and Gynecologists (ACOG) updated it committee opinion on influenza vaccination in pregnancy and post-exposure prophylaxis. This was published April 2018 and replaces Committee Opinion Number 608, September 2014.

This updated committee opinion is based on data that showed that only 54% of pregnant women in the USA were vaccinated during the 2016-2017 influenza season. This number needs to be worked on as the U.S. Health and Human Services’ Healthy People 2020 goal is vaccinating 80% of pregnant women against influenza.

Pregnant women are particularly susceptible to influenza infection and its resulting morbidities; therefore, influenza vaccination is an integral element of pre-pregnancy, prenatal, and postpartum care.

ACOG makes the following recommendations:

1) The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices and ACOG recommend that all adults receive an annual influenza vaccine. In addition, women who are pregnant or will be pregnant during the influenza season receive an inactivated influenza vaccine as soon as it is available.

2) Any of the licensed, recommended, inactivated influenza vaccine is safe during any trimester. Obstetrician-gynecologists and other health care providers should play an active part in counseling all pregnant women about the safety of influenza vaccine in pregnancy and its importance in protecting the newborn against the flu because of passive immunity.

3) It is recommended that every Obstetrician-gynecologist must get a flu vaccine every year and keep a stock of the vaccines in her office. If she is unable to provide the vaccination services, she should refer the patient to other provider, pharmacies or hospitals.

4) Patients who are allergic to egg and have had only hives can receive any licensed and recommended influenza vaccine that is otherwise appropriate for their age and health status.

5) In case the allergy symptoms are more serious than hives, the vaccine should be administered in an inpatient or outpatient medical setting including hospitals, clinics and physician offices.

6) Patients with flu-like illness should be started on antiviral medications, presuming it to be influenza. The provider should start the antiviral treatment based on clinical evaluation and not solely rely on the lab results.

7) All the office and hospital staff should also be encouraged to receive an influenza vaccine every year.

8) All pregnant women and women who are up to 2 weeks postpartum exposed to influenza virus because of close contact with an influenza patient should be started on post-exposure antiviral chemoprophylaxis (75 mg of oseltamivir once daily for 10 days). If oseltamivir is unavailable, zanamivir can be substituted, two inhalations once daily for 10 days.

Committee opinion

 Media courtesy: March of Dimes

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

First US baby born after uterine transplant delivered in Texas

The first birth as a result of uterine transplant in the United States took place on Friday in Texas at the Baylor University Medical Center in Dallas. The women had undergone a live donor transplant and have received her uterus from Taylor Siler, 36, a registered nurse in the Dallas area.

The boy delivered by elective cesarean section is just named “baby number 9, as he is the 9th person in the world to be born out of transplanted uterus.

https://obgynupdated.blogspot.in/2017/12/first-us-baby-born-after-uterine.html

New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as less invasive approach to laparoscopic surgeries. 

https://obgynupdated.blogspot.in/2018/01/new-approach-to-ovarian-cystectomy.html

ACOG updates its guidelines on Nausea and Vomiting in Pregnancy

The American College of Obstetricians and Gynecologists have updated its practice guidelines about managing Nausea and Vomiting in Pregnancy, published in the January issue of Obstetrics & Gynecology.

The guidelines replace the earlier document published in September 2015.

https://obgynupdated.blogspot.in/2017/12/acog-updates-its-guidelines-on-nausea.html

Stair-step ovulation induction protocols are not just limited to Clomiphene

Stair-step ovulation induction protocol with Letrozole is also as effective as stair-step method using Clomiphene Citrate, and has a slight edge over CC in obese patients reports the result of study published in March issue of Fertility and Sterility.

Stair-step ovulation induction protocols have shown to achieve ovulation induction in shorter time as compared to traditional protocols in women with PCOS. But, so far studies and clinical trials have mainly focused on Clomiphene Citrate(CC).

https://obgynupdated.blogspot.in/2017/12/stair-step-ovulation-induction.html

A simple, novel solution to identify and protect ureter during surgery

AllotropeMedical, a Houston based medical startup has devised StimSite, a novel, hand-held, single use device that precisely identifies ureter during surgery; thus, eliminating the need for ureteral stenting.

It is specifically useful in all gynecological, colorectal and oncosurgeries. Gynecological surgery accounts for 50% of all iatrogenic ureteric injuries.

https://obgynupdated.blogspot.in/2017/12/a-simple-novel-solution-to-identify-and.html

ACOG updates its guidance on Neural Tube Defects

ACOG has recently released its updated guidance on Neural Tube Defects (NTDs) and includes guidelines about prevention, screening, antenatal management and delivery in pregnancies with  such defects. The practice bulletin No.187 is published in December issue of Journal Obstetrics and Gynecology.

NTDs is the second most common group of congenital malformation after cardiac anomalies. The prevalence differs according to race, region and environmental influences.

In contrast to other malformations, NTDs are preventable by supplementation of folic acid.  

The recommendations:

ACOG along with other professional organizations like CDC, AAFP, AAP, ACMG and AAN: Women in the reproductive age group, having the capacity to become pregnant should take at least 0.4 mg (400 µg) of folic acid daily.

USPSTF: all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid.

ACOG, CDC other organization suggests a higher dose of 4 mg (4000 μg) of folic acid for women who are at high risk of having a baby with NTD. These factors are:

Previous history of pregnancy with NTD

Having a partner with NTDs or a partner who previously has had a child with NTD

Patients with a second or third degree relative with NTD

Patient herself was born with NTD

History of taking anti-epileptic medication Valproic acid

Type 1 Diabetes Mellitus

Obesity.

ACOG has also made additional recommendations in the recent 2017 updates.

With Advancements in Ultrasound techniques, Maternal Serum Alpha Feto Protein (MSAFP) has become less important in diagnosing NTDs, when high quality, second trimester ultrasound is routinely used.

MSAFP is more important for screening for other anomalies and placental complications in such cases.

If MSAFP value is ≥ 2.5 MoMs, the detection rate for anencephaly is 95% and 65-80% for other open NTDs.

2D ultrasound has a detection rate of 96% and if structural abnormalities are seen on Ultrasound, they can be considered diagnostic.

3D ultrasound is not superior to 2D in diagnosing NTDs; however, it may be more helpful in delineating the upper limit of spinal defects.

The rates of diagnosing NTDs in first trimester are lower than that of 2^nd trimester sonography.

MRI is not mandatory if NTD has already been identified in sonography.

Pregnancy and delivery management:

After a pregnancy with NTD is diagnosed options should be individualized according to each pregnancy:

Pregnancy termination

In Utero fetal surgery for repair

Expectant management with neonatal surgical repair.

Studies on In-Utero repairs have demonstrated that such neonates have functional level two or more times better than expected, and reduce the neonatal mortality and morbidity.

Delivery:

Regarding the timing of delivery, term delivery is preferred. Elective late preterm or early term cesarean is only considered if fetal repair has been done or other obstetric indication for surgery exists.

Retrospective studies with not very long-term follow-up have demonstrated no increased risk of vaginal delivery, but each case needs to be individualized.

Practice Bulletin Abstract

USPSTF recommendations

CDC recommendations

ACOG committee opinion on Fetal Myelomeningocele Repair

ACMG policy statements

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Media: Univision.com

ACOG recommends against vaginal seeding in Cesarean births

© Thinkstock

ACOG today issued a policy statement against the practice of vaginal seeding in cesarean deliveries, in absence of sufficient data on potential benefits associated with the procedure.

The new policy statement published in the November issue of Journal Obstetrics and Gynecology. Earlier Danish Society of Obstetrics and Gynecology has already issued a similar statement at the national meeting on 19 January 2017.

Vaginal seeding is practiced at cesarean birth and consists of transferring maternal vaginal fluid with a gauze or swab to mouth, nose, or skin of a newborn infant to inoculate him with maternal bacteria. 

This practice came into vogue following a dramatic rise in prevalence of childhood asthma, atopic disease, and other immune disorders that paralleled a steep increase in cesarean sections rate worldwide, which prevented the fetal natural colonization with maternal vaginal flora.

At present ACOG only endorse it as a part of research project in institutions under an approved protocol.

If a patient or her attended insist for the procedure, they should be fully informed about the lack of scientific data in favor of any potential benefits. They should be explained the risks associated with the procedure and the mother should be tested for infectious diseases and potentially pathogenic bacteria. Lab testing should be ordered for herpes simplex virus and cultures for group B streptococci, Chlamydia trachomatis, and Neisseria gonorrhea.

The discussion with the patient should always be documented in her medical records and take in presence of other gynecologist, family physician or pediatrician. In the event of neonatal infection or sepsis, they are at least aware of the procedure.

The relationship between breast feeding and childhood asthma and allergies remains uncertain, ACOG recommends exclusive breast feeding for the first six months of life as it has ‘multiple known benefits.’

More research is needed on the subject before the potential benefits of this procedure is documented. Till date, the only available research on vaginal seeding is the result of a small pilot study published in Nature Medicine that was able to document similarities between bacterial communities of infants delivered by cesarean section and undergone vaginal seeding and babies delivered vaginally.

Related posts:

Danish Society of Obstetrics and Gynecology recommends against vaginal seeding in Cesarean births

Microbirthing: The " Vaginal Seeding" is growing fad, but thin evidence concerns physicians!

Full Text of the committee opinion

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ACOG updates recommendations for diagnostic imaging during pregnancy and lactation

http://www.infantrisk.com/content/radiological-procedures-pregnancy

ACOG has issued recommendations addressing the concerns surrounding the use of X-ray, sonography, nuclear medicine, CT and MRI in pregnancy and lactation. The committee opinion was published in October issue of Journal Obstetrics and Gynecology.

These investigative modalities have become an integral part of our diagnostic armamentarium for evaluating acute and chronic conditions. However, there is confusion and fear surrounding these tests among physician and patients alike that many times they are delayed or totally avoided. Many a times breast feeding is stopped while patient undergo these investigations.

The ACOG’s committee on obstetric practice make the following recommendations:

Ultrasonography and MRI are safe and are the imaging modalities of choice in pregnancy and lactation, although they should be availed only when they are expected to answer a relevant clinical dilemma or are provide health benefit to the patient.

Routine radiography, computed tomography (CT) scan, or nuclear medicine imaging techniques exposes the pregnant women to a dose that is much lower than what is associated with fetal harm and so these techniques should be used if deemed necessary in addition to USG or MRI or alone if they answer the relevant clinical question.

The use of gadolinium contrast with MRI is not advised in routine practice and should only be used as contrast if it significantly improve the diagnosis and maternal and fetal outcome during pregnancy.

Breastfeeding need not be interrupted after gadolinium administration.

Nuclear Medicine imaging should be limited to the use of technetium 99m at 5 mGy when indicated during pregnancy. 

Radioactive iodine (iodine 131) readily crosses placenta and is absolutely contraindicated in pregnancy.

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ACOG issues clinical practice guidelines for Gestational Diabetes Mellitus

Courtesy: YouTube.

The American College of Obstetricians and Gynecologists (ACOG) has issued clinical practice guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM).

Although prevalence of GDM is directly proportional to prevalence of type 2 DM in a given population, it is estimated that GDM accounts for 90% of cases diabetes in pregnancy. The prevalence of DM in pregnancy is around 6-9%.

The prevalence of GDM globally is on the rise because of increasing obesity, delayed childbearing and sedentary lifestyle.

The document provides a brief overview of GDM, one of the most common complication of pregnancy, identifies the disease process, its diagnosis and management based on current research and identifies the lacunae for future research.

Screening for GDM is done by various methods and there is still no standardized method. ACOG supports the two-step process most commonly used in USA. It involves first screening with the administration of a 50-g oral glucose solution followed by a 1-hour venous glucose determination. 

Women whose glucose levels meet or exceed an institution’s screening threshold then undergo a 100-g, 3-hour diagnostic OGTT. Gestational diabetes mellitus is most often diagnosed in women who have two or more abnormal values on the 3-hour OGTT.

Other institutions and private practitioners use International Association of Diabetes and Pregnancy Study Group (IADPSG) recommended one step, universal 75-g, 2-hour OGTT to diagnose GDM.

The summary of recommendations by ACOG:

Recommendations based on good scientific evidence (Level A):

All women diagnosed with GDM should first be treated with adequate nutritional and exercise counselling, before starting any pharmacological treatment.

If lifestyle modifications fail to control glucose levels, Insulin is the first line of drug for controlling blood sugar in pregnancy.

Recommendations based on limited or inconsistent scientific evidence (Level B):

All pregnant women should be screened for GDM with a laboratory based blood glucose level testing.

Women who refuse to take insulin, or who are unable to safely administer insulin, metformin is a reasonable second-line choice.

Glyburide is not be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin.

All women should be counselled about limitations of safety data regarding oral hypoglycemic agents.

Women should also receive counselling regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 g or more.

Recommendations based primarily on consensus and expert opinion (Level C):

In the absence of clear evidence and comparative trials, no single value of blood glucose can be taken as cutoff over another for 1-hour glucose test nor one set of diagnostic criteria for the 3-hour OGTT can be clearly recommended over the other. Practitioners should select a single set of criteria and use it consistently with their patients.

Women should be advised dietary guidance and 30 minutes of moderate physical activity, 5 days a week or 150 minute/week.  

In women, whose GDM is well controlled by diet and exercise, delivery is not indicated before 39 weeks of gestation, in absence of other obstetric indication. She can be safely managed expectantly up to 40 6/7 weeks of gestation, with antepartum fetal surveillance.

In women, whose GDM is well controlled by medications, delivery is recommended at 39 0/7 to 39 6/7 weeks of gestation.

All women with GDM should be screened at 4–12 weeks postpartum to identify women with diabetes, impaired fasting glucose levels, or impaired glucose tolerance, with an appropriate referral to medical practitioner.

The American Diabetic Association (ADA) and ACOG recommend repeat testing every 1–3 years for women who had a pregnancy affected by GDM and normal postpartum screening test results.

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