What’s new in the other journals?
Urodynamic testing before surgery
Women presenting with urinary stress incontinence are frequently subjected to urodynamic testing before surgery. This would appear to be a logical approach but if stress incontinence is demonstrable on clinical evaluation— does the addition of dynamics make any difference to the eventual outcome of the management? If not, can the tests be safely omitted, saving the woman time, money and the risk of instrumentally introduced infection?
Specifically to address this questions a trial was conducted on the use of urodynamic testing in 11 different centres in the USA, allocating half of the women to evaluation only, and the other half to evaluation plus urodynamic testing according to standardised protocols (Nager et al. N Engl J Med 2012;366:1987–97). The end point was the percentage of each group in whom the treatment was successful, with the principle of non-inferiority being set in advance. Over 600 women were randomly entered into the trial and reviewed 1 year after surgery. Both groups had 77% successful outcomes, allowing the researchers to assert that in women with uncomplicated, demonstrable stress urinary incontinence, preoperative urodynamic testing does not affect the result and is therefore unnecessary.
Reproductive technology and birth defects
The risk of having a child with a birth defect is greater after conceiving with assisted reproductive technology compared with spontaneous conception. Of course the vast majority of assisted or unassisted pregnancies result in healthy infants, but couples entering assisted reproduction programmes are entitled to know if the process on which they are embarking will result in a child with a defect or not. It is not a simple question to answer because it requires accurate statistics of defects in the population at large, recording of those conceived with assistance, and the calculation of the likelihood of any defects being caused by the technique used over and above the background risk of both particular parents.
To provide answers, Davies et al. (N Engl J Med 2012;366:1803–13) studied the South Australian birth registry spanning 15 years. This contained data about infants’ type of conception and linked it to the birth defects registry for the region. The registry had complete information about all children at the age of 5 years. Defects of the cardiovascular, musculoskeletal, urogenital and gastrointestinal systems were recorded as well as cerebral palsy, and their relationship to ovulation induction, in vitro fertilisation and intracytoplasmic sperm injection techniques plus the parents’ age and reproductive history was assessed.
It turns out that there is a greater risk to those born using assisted reproductive therapy (8% versus 6% using their criteria) but the cause of the risk is attributable to the parental profile rather than to the assisted reproductive technique used. In other words, if these couples were to conceive spontaneously their risk would remain raised to the same degree and manipulations (other than intracytoplasmic sperm injection) do not change the odds.
This study will reassure those working with couples experiencing infertility that most of their techniques are unlikely to increase the slightly raised risk they already have of conceiving a child with a defect.
Preterm prelabour rupture of membranes and induction
In pregnancies between 34 and 37 weeks of gestation where the membranes rupture but labour does not ensue, clinicians face a dilemma. Induction will lead to the increased risk of neonatal complications of early delivery but expectant management may allow the development of chorioamnionitis. To address this question, a randomised controlled trial was carried out in 60 hospitals in the Netherlands, in which half of the pregnancies with preterm rupture of the membranes were induced and half were treated expectantly (van der Ham et al. PLoS 2012;9:e1001208).
The trial randomised over 500 pregnancies and the primary outcome was the presence or absence of neonatal sepsis. The sepsis rate was 58% higher in the expectant group, being 4.1% versus 2.6% in the induction group, but the difference was not statistically significant (relative risk [RR] 0.64; 95% CI 0.25–1.6). Secondary outcomes such as neonatal hypoglycaemia and hyperbilirubinaemia were significantly increased by induction (RR 2.2 and 1.5), but histological evidence of chorioamnionitis was reduced (RR 0.40). A meta-analysis including eight previous trials showed no significant differences in any of the major outcomes. The obvious conclusion is that either induction of labour or expectant management remain reasonable alternatives and management can be therefore tailored to individual circumstances (e.g. the availability and cost of neonatal care and womens’ preferences).
Neonatal abstinence syndrome
The neonatal abstinence syndrome refers to the state of postnatal drug withdrawal in neonates whose mothers have used habituating drugs during pregnancy.
The term neonatal abstinence syndrome is most commonly used when referring to newborns exposed to opiates in utero but may refer to withdrawal from any illicit drug use and indeed women using one drug are prone to use others like nicotine and alcohol. A survey by Patrick et al. from the USA (JAMA 2012;307:1934–40) highlights the increasing problem in that country, particularly the misuse of prescribed opiates (which is reaching epidemic proportions).
As usual, it is the underprivileged, poor and least educated who are most at risk of drug abuse and are more likely to deliver infants that are growth restricted and have higher perinatal mortality rates. Their babies show increased irritability, hypertonia, tremors, feeding intolerance with vomiting, watery stools, seizures and respiratory distress. Treatment is difficult, often with prolonged weaning-off required, which itself means mother–infant separation leading to poorer bonding, with less breastfeeding, setting up a cycle for deprivation requiring more intensive care to correct.
Managing the third stage of labour
The active management of the third stage of labour has been shown to substantially lower the risk of postpartum haemorrhage (PPH). The two key components in active management are the administration of a uterotonic agent and controlled cord traction to facilitate delivery of the placenta. Both aspects seem straightforward enough but in situations of limited resources and skills, it may be important to decide which of the two steps is more important in PPH prevention.
Gulmezoglu et al. (Lancet 2012;379:1721–7) conducted a trial in developing countries that showed that the giving of a uterotonic agent and not controlled cord traction was the most important factor protecting against PPH in challenging circumstances. This outcome allows future energies to be directed to the delivery of uterotonic agents—prepacked disposable oxytocin syringes or misoprostol—rather than to the teaching of controlled cord traction skills.
Traction skills require education if uterine inversion is to be avoided, and attention to it as a priority may encourage early cord clamping with its detrimental neonatal and infant effects. Where real basic obstetric needs are as yet unmet, there needs to be rigorous research into what is essential for life-saving care and what is incidental. This study adds to such basic knowledge.
Termination of pregnancy and misoprostol
About one-third of all pregnancies are terminated worldwide. Where termination of pregnancy (TOP) is carried out legally, the most common method is by vacuum aspiration in the first trimester, so any means whereby this procedure can be made more efficient or safer would be beneficial to millions of women. One such advance is the use of misoprostol as an adjunct medication before dilatation and aspiration.
Misoprostol 400 micrograms introduced intravaginally 3 hours preoperatively by the woman or a healthcare worker is widely recommended but proof of its benefit in terms of reducing complications has been lacking. Now a World Health Organization group has published the results of a trial of almost 5000 women comparing misoprostol premedication with placebo in terms of facilitating the TOP and reducing complications including the need for re-evacuation (Meirik et al. Lancet 2012;379:1817–24).
Their records showed that the starting cervical dilatation in those receiving misoprostol was greater than in those given placebo, and with manual dilatation a larger bore curette was able to be introduced. The researchers considered that this made aspiration more efficient, resulting in fewer women needing re-evacuation. In addition, the overall incidence of complications such as cervical trauma was reduced, as was the incidence of complications causing clinic revisits, while untoward outcomes such as uterine perforation or postprocedure infections were equally distributed between the two study arms. There were side-effects from the misoprostol, namely abdominal pain (55% versus 22%) and vaginal bleeding (37% versus 7%) and the authors recommend that women should be warned of these possibilities.
The data are convincing and derived from large numbers in differing venues in various countries. As Templeton cogently argues, surely it is time that misoprostol preparation should precede all aspiration TOPs (Lancet 2012;379:1772–3).
Is coffee good for you?
Coffee contains the stimulant caffeine, which intuitively excludes its consumption as part of a healthy lifestyle. But it is also a rich source of antioxidants and drinking coffee has been shown to reduce markers of inflammation and insulin resistance.
Previous reports on coffee’s risks and benefits have been based on limited evidence but now a survey of over half a million middle-aged people for more than a decade shows that, on balance, coffee is good for you, especially if you are a woman. (Freedman et al. N Engl J Med 2012;366:1891–904). The researchers showed that one’s risk of mortality decreased in a dose-related fashion with increasing numbers of cups of coffee drunk per day—provided you do not smoke. At six cups per day men had a 10% reduction in mortality rates and women a 15% reduction. It did not matter if the coffee was decaffeinated or not and all causes of death were reduced except those from cancer.
Even breastfeeding mothers need not be wary of drinking coffee. A study, appropriately from Brazil, looked at mothers’ coffee consumption in pregnancy and postpartum and related their intake to the number of times their babies woke up at night (Santos et al. Pediatrics 2012;129:860–8). It made no difference to the baby’s sleep patterns so breastfeeding mothers need not be concerned about enjoying coffee.
Coffee can very much be part of a healthy lifestyle.
These snippets are excerts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at email@example.com or visit the website http://www.getjass.com.