<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_319"
                     title="Internal Monitoring During Induced Labor of Little Help (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18186?impressionId=1265747770196"
                     
      &lt;p&gt;Internally monitoring the progress of induced labor may not improve outcomes for mother or baby, Dutch researchers found.&lt;/p&gt;
&lt;p&gt;Internal tocodynamometry did not reduce the rate of operative delivery compared with external monitoring (31.3% versus 29.6%, &lt;em&gt;P&lt;/em&gt;=0.50) in a study led by Jannet J.H. Bakker, MSc, of the Academic Medical Center in Amsterdam.&lt;/p&gt;
&lt;p&gt;Nor did it significantly reduce risk of adverse neonatal outcomes, Bakker&apos;s group reported in the Jan. 28 &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Some obstetrical professional associations recommend routine internal monitoring to assess contractions accurately. Others, such as the American College of Obstetricians and Gynecologists, suggest it only in special circumstances, such as when induction response is limited, or if the mother is obese.&lt;/p&gt;
&lt;p&gt;Researchers had hoped that internal monitoring might improve doctors&apos; ability to effectively dose labor-inducing oxytocin, leading to less distress for babies and fewer operative deliveries, the investigators noted.&lt;/p&gt;
&lt;p&gt;Given the limited power of the only three prior studies comparing monitoring methods, the researchers undertook a randomized, controlled trial in six hospitals in the Netherlands.&lt;/p&gt;
&lt;p&gt;Overall, 1,456 women who agreed to participate in the study and required intravenous oxytocin for induction or augmentation of labor were randomized to &quot;open-label&quot; internal tocodynamometry with a sensor-tipped intrauterine catheter system (Koala) or monitoring with an external tocodynamometer.&lt;/p&gt;
&lt;p&gt;Crossover to internal monitoring was allowed if women had no cervical progression for two hours, if uterine contractions were insufficient, or if doctors were considering cesarean section.&lt;/p&gt;
&lt;p&gt;For the primary endpoint by intention-to-treat, women were no less likely to have cesarean or instrumented vaginal delivery with internal monitoring (RR 1.1 versus external monitoring, 95% CI 0.91 to 1.2).&lt;/p&gt;
&lt;p&gt;For cesarean section alone, the confidence interval ranged from a 17% risk reduction to a 30% increase with internal tocodynamometry. Researchers said this would fit in with the prior small trials  --  all of which showed a nonsignificant increase in cesarean delivery.&lt;/p&gt;
&lt;p&gt;Nor were there significant benefits seen with internal monitoring for any secondary outcome. These included: &lt;ul&gt; &lt;li&gt;A composite of adverse neonatal outcomes  --  defined as an Apgar score at five minutes of less than 7, umbilical-artery pH of less than 7.05, or neonatal hospital stay longer than 48 hours (RR 0.95, &lt;em&gt;P&lt;/em&gt;=0.70) &lt;/li&gt; &lt;li&gt;Use of antibiotics during labor (RR 0.81, &lt;em&gt;P&lt;/em&gt;=0.10) &lt;/li&gt; &lt;li&gt;Use of analgesia (RR 1.0, &lt;em&gt;P&lt;/em&gt;=0.75) &lt;/li&gt; &lt;li&gt;Time from randomization to delivery (313 minutes versus 358 for induced labor, &lt;em&gt;P&lt;/em&gt;=0.93) and (299 minutes versus 386 for augmented labor, &lt;em&gt;P&lt;/em&gt;=0.94) &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The findings remained similar between groups when outcomes were considered according to actual treatment.&lt;/p&gt;
&lt;p&gt;Notably, some of the patient subgroups specifically recommended for internal uterine activity monitoring  --  such as those with high body mass index  --  showed no benefit, either.&lt;/p&gt;
&lt;p&gt;There were no treatment interactions by type of labor, parity, or body mass index.&lt;/p&gt;
&lt;p&gt;The researchers recommended cautious interpretation of these post hoc results, with limited power.&lt;/p&gt;
&lt;p&gt;Furthermore, while there were no reported complications associated with the monitoring and no deaths occurred in either group, Bakker and colleagues noted that the study was not powered to detect some risks. These included placental or fetal-vessel damage, infection, and anaphylactic reaction, which in prior studies have an incidence of 1 in 300 to 1 in 1,400.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_235"
                     title="Congenital Anomalies Linked to Mom&apos;s Diabetes (CME/CE)"
                     score="-0.001"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18065?impressionId=1265747770196"
                     
      &lt;p&gt;Pregestational maternal diabetes was associated with an increased risk of a major congenital anomaly, but obesity itself was not, a cross-sectional study found.&lt;/p&gt;
&lt;p&gt;In a multivariable logistic model, the major contributor to a rising rate of congenital anomalies was maternal pregestational diabetes (OR 3.8, 95% CI 2.1 to 6.6), according to Joseph R. Biggio, Jr., MD, and colleagues from the University of Alabama at Birmingham.&lt;/p&gt;
&lt;p&gt;&quot;Because hyperglycemia is a major contributor to developmental malformations, interventions to address obesity and identify women at risk for diabetes and hyperglycemia should be considered in efforts to reduce the occurrence of congenital anomalies,&quot; they wrote in the February issue of &lt;em&gt;Obstetrics &amp;amp; Gynecology.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Maternal obesity has been linked with numerous problems, including preeclampsia, gestational diabetes, fetal and neonatal death, and birth trauma, but scientists have disagreed over whether it also contributes to the risk of fetal malformations, the researchers noted.&lt;/p&gt;
&lt;p&gt;To help settle the issue, Biggio and colleagues used a perinatal database in their university health system that included all women with singletons delivered between 1991 and 2004.&lt;/p&gt;
&lt;p&gt;They divided the cohort into three time periods  --  1991 to 1994, 1995 to 1999, and 2000 to 2004, with a total of 41,902 pregnancies.&lt;/p&gt;
&lt;p&gt;For their primary analysis, they defined maternal obesity as a first prenatal visit weight greater than 200 lb, because during the earlier epochs many women did not have body mass index (BMI) calculated. For their secondary analyses they used BMI greater than 29 kg/m&lt;sup&gt;2&lt;/sup&gt; as the criterion for obesity.&lt;/p&gt;
&lt;p&gt;In each epoch, there were increases in mean maternal weight, mean BMI, the proportion of women weighing more than 200 lb, the proportion with a BMI greater than 29 kg/m&lt;sup&gt;2&lt;/sup&gt;, and the prevalence of pregestational diabetes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for all).&lt;/p&gt;
&lt;p&gt;Univariable analysis determined that the rate of major anomalies, particularly involving the cardiac and pulmonary systems, also increased during each time period.&lt;/p&gt;
&lt;p&gt;But there was no independent association between congenital anomalies and maternal obesity using either definition, during any of the three time periods or during the study overall.&lt;/p&gt;
&lt;p&gt;Although no direct association was seen between congenital malformations and maternal obesity, the investigators reported that the proportion of anomalies that could be attributed to obesity increased from 0% to 23% during the overall study period.&lt;/p&gt;
&lt;p&gt;The proportion of anomalies that could be attributed to diabetes ranged from 58% to 76%.&lt;/p&gt;
&lt;p&gt;Moreover, for obese women with diabetes the proportion of anomalies attributed to diabetes increased sharply, from 48% in the first epoch to 74% in the third epoch.&lt;/p&gt;
&lt;p&gt;In contrast, for the obstetric population as a whole, the population-attributable risk of congenital malformation related to obesity rose from near zero in the first epoch to 6.1% in the third epoch, while that related to diabetes increased from 3.3% to 9.2%, the investigators reported.&lt;/p&gt;
&lt;p&gt;During the course of the study there was a nearly 15-lb increase in maternal weight and a 30% increase in the proportion of women whose BMI exceeded 29 kg/m&lt;sup&gt;2&lt;/sup&gt;.&lt;/p&gt;
&lt;p&gt;There also was a nearly twofold increase in the rate of major anomalies  --  and a 250% increase in the prevalence of diabetes.&lt;/p&gt;
&lt;p&gt;The authors observed that there has been much interest in the effects of maternal obesity on birth defects.&lt;/p&gt;
&lt;p&gt;Although the pathophysiologic basis for this possible association have not been identified, hypotheses have included increased serum insulin, lower levels of folic acid, chronic hypoxia, and increased inflammatory mediators.&lt;/p&gt;
&lt;p&gt;&quot;Our study provides evidence that the defects may not be due solely to the maternal obesity per se but may be due to undiagnosed diabetes,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;From a public health standpoint, the study findings suggest that efforts to reduce the prevalence of congenital anomalies should be focused less on obesity and aimed more closely at correcting hyperglycemia.&lt;/p&gt;
&lt;p&gt;&quot;If euglycemia could be achieved before pregnancy, or at least embryogenesis and organogenesis, the majority of these anomalies could potentially be avoided,&quot; they observed.&lt;/p&gt;
&lt;p&gt;They also suggested that even women of normal weight, but with other diabetes risk factors, could benefit from closer attention to glycemic control.&lt;/p&gt;
&lt;p&gt;A weakness of the study was the fact that detailed data on glycemic control was not available in the perinatal database, &quot;and therefore we cannot comment on the association between glycemic control and anomaly rates,&quot; the investigators wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported in part by the National Institute of Child Health and Human Development.&lt;/p&gt;&lt;p&gt;The authors did not report any potential conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_212"
                     title="No Need for Most Moms to Fast During Labor (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18059?impressionId=1265747770196"
                     
      &lt;p&gt;Although conventional wisdom has long held that women shouldn&apos;t eat or drink during labor, the scientific evidence suggests there&apos;s no reason for the prohibition, according to a new meta-analysis.&lt;/p&gt;
&lt;p&gt;&quot;Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications,&quot; Mandisa Singata, MBA, RM, RN, of the University of the Witwatersrand in East London, South Africa, and colleagues concluded in a Cochrane review.&lt;/p&gt;
&lt;p&gt;They identified five studies involving 3,130 women that examined whether food and drink during labor affected outcomes such as rates of cesarean section, operative vaginal births, or Apgar scores. No significant advantage was found for restricting access to food or liquids on any outcome, Singata and colleagues found.&lt;/p&gt;
&lt;p&gt;Until the 1940s, women were generally encouraged to eat and drink during labor  --  often specific foods and fluids  --  to keep up their strength.&lt;/p&gt;
&lt;p&gt;But a 1946 paper and other publications by Curtis Lewis Mendelson suggested that access to food increased the risk that women under anesthesia would aspirate acidic stomach contents during labor, potentially causing serious lung injury and even death.&lt;/p&gt;
&lt;p&gt;Mendelson&apos;s work persuaded many obstetricians to urge that women fast until after delivery, according to Singata and colleagues.&lt;/p&gt;
&lt;p&gt;The researchers cited a 1988 survey of U.S. hospitals that found almost half allowed only ice chips, although more recent trends suggested that access to food and liquids had increased, at least in Great Britain.&lt;/p&gt;
&lt;p&gt;They noted that some women in labor don&apos;t feel like eating but others regard restrictions as &quot;unpleasant and sometimes harrowing.&quot;&lt;/p&gt;
&lt;p&gt;One reason for revisiting Mendelson&apos;s research is that anesthesia procedures have changed markedly since the 1940s, with regurgitation of stomach contents now considered very rare.&lt;/p&gt;
&lt;p&gt;&quot;The policy of routine restriction of foods and fluids in labor in many hospitals across the world generally does not reflect women&apos;s preferences or cultural expectations,&quot; Singata and colleagues wrote. &quot;It is critical that any policy should be based on evidence of overall benefit to women and babies.&quot;&lt;/p&gt;
&lt;p&gt;Searching the literature, Singata and colleagues found five randomized trials that had compared more versus less restrictive nutrition regimens.&lt;/p&gt;
&lt;p&gt;Only one of the trials tested free access to any kind of food and drink against restriction to ice chips or sips of water. The other four examined particular classes of nutritive foods or drinks.&lt;/p&gt;
&lt;p&gt;Two tested electrolyte-carbohydrate sports drinks and two others evaluated low-fat and/or low-residue foods, all against water or ice chips.&lt;/p&gt;
&lt;p&gt;Pooling data from the five studies, Singata and colleagues calculated relative risks for three major adverse outcomes for allowing access to nutrition, versus water or ice chips: &lt;ul&gt; &lt;li&gt;Cesarean section: RR 0.89, 95% CI 0.63 to 1.25&lt;/li&gt; &lt;li&gt;Operative vaginal birth: RR 0.98, 95% CI 0.88 to 1.10&lt;/li&gt; &lt;li&gt;Apgar scores &amp;lt;7 at five minutes: RR 1.43, 95% CI 0.77 to 2.68&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The meta-analysis also examined eight other outcomes, such as maternal ketosis and nausea and vomiting, infant admission to intensive care, and augmentation of labor. There were no significant differences in any of these outcomes between allowing and restricting access to nutrition.&lt;/p&gt;
&lt;p&gt;The sole study comparing unlimited access to food and drink to water or ice chips, which had 330 participants, also found no effects on either primary or secondary outcomes in either direction.&lt;/p&gt;
&lt;p&gt;None of the studies examined women&apos;s perceptions of the labor experience based on whether or not they had access to nutrition.&lt;/p&gt;
&lt;p&gt;Singata and colleagues called the overall quality of evidence &quot;reasonable.&quot; But they noted that none of the studies enrolled women at increased risk of needing general anesthesia, so the conclusions should be interpreted as applying only to women at low risk of complications.&lt;/p&gt;
&lt;p&gt;The studies also left some questions unanswered. For example, one of the two sports drink studies found that C-section rates were lower in participants who drank plain water, but no such result was seen in the other.&lt;/p&gt;
&lt;p&gt;&quot;It would be worth comparing the use of carbohydrate drinks ... with freedom to eat and drink at will during labour to see if this really is a problem,&quot; Singata and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Moreover, they suggested, &quot;a better approach&quot; to the rare problem of inhaling regurgitated material while under anesthesia during labor may be to test treatments intended to reduce acidity and volume of stomach contents, now used during elective C-sections.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;External funding for the study came from the World Health Organization and the U.K. National Institute for Health Research.&lt;/p&gt;&lt;p&gt;One author of the review was principal author of one of the studies included in the meta-analysis, but did not participate in decisions regarding data from that study. No other potential conflicts were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_203"
                     title="Doppler Exam Improves Outcomes in High-Risk Pregnancy (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18044?impressionId=1265747770196"
                     
      Using Doppler ultrasound to examine fetal circulation reduces perinatal death in high-risk pregnancies by 29%, an updated Cochrane Review found.&lt;br&gt;
&lt;br&gt;In a pooled analysis of 16 studies involving 10,225 babies, the perinatal death rate was 1.2% when Doppler ultrasound was used and 1.7% when it was not, according to Zarko Alfirevic, MD, of the University of Liverpool in England, and colleagues.&lt;br&gt;
&lt;br&gt;The number needed to treat was 203 (95% CI 103 to 4352).&lt;br&gt;
&lt;br&gt;In an interview, Alfirevic said that that high number and &quot;absolutely huge&quot; confidence interval reflects the lack of quality evidence.&lt;br&gt;
&lt;br&gt;&quot;I think that, indeed, one can question whether this is a good value for money,&quot; he said, noting that there have not been any formal cost-effectiveness analyses.&lt;br&gt;
&lt;br&gt;But, because there are no obvious negative effects from the examination, he said, &quot;I would expect that most patients would say Yes.&quot;&lt;p&gt;&lt;/p&gt;
&lt;p&gt;The review updated a previous one conducted in 1996, which came to similar conclusions about the use of Doppler ultrasound.&lt;/p&gt;
&lt;p&gt;Abnormal fetal circulation detected on ultrasound may indicate poor fetal prognosis and allow life-saving interventions to be performed.&lt;/p&gt;
&lt;p&gt;However, a false-positive finding could encourage inappropriate early delivery, which could result in increased problems associated with prematurity, Alfirevic and his colleagues wrote.&lt;/p&gt;
&lt;p&gt;So they conducted a review to assess the risks and benefits of adding Doppler ultrasound to protocols for evaluating fetal well-being in women with high-risk pregnancies, including those with diabetes, hypertension, and heart problems or those with intrauterine growth restriction, pregnancies that have progressed beyond term, and those who&apos;ve had a previous miscarriage or stillbirth.&lt;/p&gt;
&lt;p&gt;The researchers looked at randomized and quasi-randomized controlled trials comparing the use of Doppler ultrasound with no ultrasound or with electronic fetal monitoring. In general, they said, the studies were not high quality.&lt;/p&gt;
&lt;p&gt;In fact, the quality of the studies assessing Doppler ultrasound versus no ultrasound for the effect on perinatal death rates was &quot;very low,&quot; the authors wrote, which is &quot;of concern given the borderline significance of the pooled meta-analysis result.&quot;&lt;/p&gt;
&lt;p&gt;There was insufficient evidence to assess the effect of the use of ultrasound on serious neonatal morbidity, the other primary outcome.&lt;/p&gt;
&lt;p&gt;Although Alfirevic said he and his colleagues were concerned that the use of Doppler ultrasound might increase invasive obstetrical procedures, in 10 of the studies there were actually fewer inductions of labor (pooled RR 0.89, 95% CI 0.80 to 0.99) and fewer cesarean deliveries in 14 studies (pooled RR 0.90, 95% CI 0.84 to 0.97).&lt;/p&gt;
&lt;p&gt;The use of Doppler ultrasound had no effect on rates of operative vaginal births or on the proportion of babies born with Apgar scores under 7 at five minutes.&lt;/p&gt;
&lt;p&gt;According to Alfirevic, the overall low quality of the evidence did not allow for recommendations regarding patients who would most benefit from the addition of Doppler ultrasound or regarding the best approaches following an abnormal result.&lt;/p&gt;
&lt;p&gt;&quot;Doppler studies of the umbilical artery should be incorporated and should be a part of the protocols for fetal monitoring in high-risk pregnancies, particularly those who are at risk of placental insufficiency,&quot; he said.&lt;/p&gt;
&lt;p&gt;&quot;But we are not in a position at the moment to be more specific than that.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The review received internal support from the University of Liverpool and external support from the U.K. National Institute for Health Research (NIHR). One of Alfirevic&apos;s co-authors is supported by the NIHR NHS Cochrane Collaboration Program grant scheme award for NHS-prioritized centrally-managed, pregnancy and childbirth systematic reviews.&lt;/p&gt;&lt;p&gt;The authors reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_3_487"
                     title="Induced Labor Doubles Risk of Rare Pregnancy Complication"
                     score="-0.005"
                     href="