RECENTLY PUBLISHED PAPERS
IMPORTANT TO YOUR PRACTICE
JAMES R. SCOTT, MD
I have no conflict of interest to disclose.
OBJECTIVES
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TO BE FAMILIAR WITH PRACTICE
CHANGING STUDIES IN PAST YEAR
TO ANTICIPATE INTENDED AND
UNINTENDED CONSEQUENCES
TO APPLY THIS INFORMATION
IN YOUR OWN PRACTICE
MY TOP STUDIES FOR 2014 THAT WILL
AFFECT OR CHANGE YOUR PRACTICE
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GENERAL THEMES WERE SAFETY,
QUALITY BASED ON EVIDENCE & COST
SELECTED ONLY PRACTICAL NEW
PAPERS FOR EVERYDAY PATIENT CARE
1/2 OBSTETRICS & 1/2 GYNECOLOGY
CHALLENGE: TO TRANSLATE
IMPERSONAL & DOGMATIC STATISTICS
INTO INDIVIDUALIZED CARE OF REAL
PEOPLE
CHOOSING WISELY INITIATIVE
Joint Commission, >50 National Medical Societies
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PAPER/ABSTRACT/
DEFINITION OF
OVERUSE
DEFINITION OF OVERUSE
TESTS OR TREATMENTS
THAT PROVIDE NO
BENEFIT TO PATIENTS,
POTENTIALLY EXPOSING
THEM TO HARM
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TRULY NECESSARY
FREE FROM HARM
NOT DUPLICATIVE
SUPPORTED BY
EVIDENCEE
LAST YEAR ACOG LIST – PHYSICIANS
SHOULD STOP DOING:
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Elective inductions or Cesareans before 39 wks
Elective inductions between 39-41 wks unless
cervix is favorable
Routine annual Pap tests in women age 30-65
Treating patients with mild dysplasia less than
2 years duration
Screening for ovarian cancer in women at
average risk
http://www.choosingwisely.org
HEADS UP: CURRENTLY UNDER
CONSIDERATION FOR SECOND LIST
DON’T:
 Use Terbutaline for > 48 hrs to prevent
preterm birth
 Use Robotic surgery when not indicated
 Perform pelvic ultrasounds in asymptomatic
non-pregnant women
 Perform urodynamic testing in women with
simple SUI
 Prescribe bed rest during pregnancy
 Routinely Transfuse for Hb over 7 g/dl
PROPHYLACTIC ANTIBIOTICS FOR CESAREAN
Obstet Gynecol 2014;124(2):338.
BOTTOM LINE
• Only 59% Received
Appropriate Pre-Op
Antibiotics
• 3.2% Got Wrong Dose
or Wrong Antibiotic
SIGNIFICANCE
• Post Op Infections Cost
$10,000 (Ave) and >
Hospital Stay
• Proper Prophylaxis
Lowers Infection Rates
by 65% MPT 0P INFECTIONS COST >$L STAY
PROPE LOWERS INF
CLINICALLY IMPORTANT
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SIMPLE REGIMEN
– 1 GM IV OF CHEAPEST CEPHALOSPORIN
(ex. Cefazolin/Ancef) BEFORE SKIN INCISION
FOR ALL HYSTERECTOMIES & CESAREANS
– USE 2 GM FOR OBESE PT
– ADD 1 GM AT 3 HOURS or WITH >1500 ML
BLOOD LOSS
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“TIME OUT” CHECKLIST
CHECK OUT YOUR HOSPITAL MONITORED BENCHMARK
AN ASIDE – RECENT FDA WARNINGS
FOR ANTIBIOTICS TO KNOW ABOUT
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AZITHROMYCIN (ZITHROMAX) – Can Prolong
QT Interval  Arrhythmia & Death (rare)
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FLOURIQUINOLONES Such as CIPROFLOXIN
(CIPRO) Can Cause Acute Neuropathy
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CLARIYTHROMYCIN (BIAXIN) Combined with
Calcium-Channel Blockers (PROCARDIA) can
cause Kidney Damage, Hypotension & Death
THE ONGOING VBAC SAGA
BJOG Jan 2014 ur After Caesarean Delivery: Evidence and
Experience. BJOG Jan 2013 (insert exact reference)
ANOTHER CONSEQUENCE
OF HIGH CESAREAN RATE
Intrapartum Management
Similar to Pt Without
Previous Cesarean EXCEPT:
– Induction with Unripe
Cervix
– Oxytocin Stimulation
– Surveillance for
Uterine Rupture
UNIVERSITY OF UTAH
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33 YR OLD G-6 P-4 @ 40 WKS
CESAREAN WITH LAST DELIVERY
WANTS VBAC
IN LABOR  ABNORMAL FHR TRACING
EMERGENCY CESAREAN  DELIVERED
IN ~15 MINUTES
BABYS: APGARS - 0,3,4 CORD pH 6.76
NBICU – COOLING PROTOCOL
MEDIA: VBAC REFUSALS CUT OPTIONS
The New York Times
CASPER, WYO. – When
April 14, 2014
Marie became pregnant
again, she wanted a
VBAC. But she quickly
learned that the only fullservice hospital within
easy driving distance (in
Casper) had a policy
against VBACs. So she
traveled 180 miles to a
hospital in Cheyenne
willing to perform the
procedure.
MY VIEW
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VBAC REMAINS DILEMMA WITH NO
PERFECT ANSWER
SUPPORT VBAC BUT BE CAREFUL
EVALUATE, COMMON SENSE, JUDGEMENT
ITS ALL ABOUT UTERINE RUPTURE – RARE
BUT CAN BE DEVASTATING FOR MOTHER,
BABY (AND PHYSICIAN)
HOW MUCH RISK WILLING TO ASSUME?
BE PREPARED AND BE AROUND
SOLUTION: PREVENT FIRST CESAREAN
Obstet Gynecol 2014;(3):693-711.
BOTTOM LINE
• Active Labor Begins at
6 cm Cervical Dilation
(not 4 cm)
• Arrest of Labor  Use
Pitocin
• At least 4 hours of
Adequate Contractions
• Second Stage – Allow
Multips to Push for at
Least 2 hours & Primips
for at Least 3 hours
GROWING CONSENSUS
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TOO MANY UNNECESSARY CESAREANS
HARD TO BELIEVE THAT 33% OF WOMEN
NEED TO BE DELIVERED ABDOMINALLY
COMING BACK TO HAUNT US WITH
ACRETAS & MATERNAL MORBIDITY
MY PREDICTION - WILL TAKE YEARS
FOR BACKLASH & DOCS TO START
DOING SOMETHING TO LOWER RATE
BETTER TO START NOW
INCREASING PROBLEM:
PLACENTA ACCRETA
FALLOPIAN TUBE IS ORIGIN OF MANY
OVARIAN CANCERS
AJOG 2013;209(5):409-14.ancer. AJOG 2013;209(5):409-14.
TOTAL SALPINGECTOMY AT HYSTERECTOMY
AND TUBAL STERILIZATION
AJOG 2014;210:471-82
• Hysterectomy with
Salpingectomy or
Salpingectomy
instead of T.L. vs
Controls
• 43,931 Women
• Increased O.R. Time
by 10-16 min.
• Safe – No Increased
Complications over
Control Group
IMPLICATIONS: CONSIDER SALPINGECTOMY
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1 in 70 Lifetime risk of Ovarian CA
No Effective Screening
Majority of “Ovarian” Cancers Arise in
Distal Fallopian Tube
Salpingectomy Could Decrease Risk by 40%
Exact Long-term Risks and Benefits Not Yet
Defined
DISCUSS WITH PATIENT
MALIGNANCY IN ENDOMETRIAL POLYPS (1027 Cases)
Europ J Obstet Gynecol Reprod Biol 2014;(Oct 29)
• pi
BOTTOM LINE
• Benign – 95.8%
• Pre-Malignant – 2.7%
• Malignant – 1.54%
• NOTE: HIGHER THAN
PREVIOUSLY THOUGHT
• Post Menopausal
Women at Greater Risk
& Greater Risk for
Endometrial Cancer
MERINA IUD AS CONSERVATIVE Rx FOR ENDOMETRIAL
HYPERPLASIA AND EARLY CANCER BJOG 2014;121:477-86.
•
BOTTOM LINE
• Option for Fertility
Preservation in Young
Women
• Excellent response &
regression rate (100%) at
6 mo.
• Works well in hyperplasia,
less so in endometrial
cancer
• All Need Close Monitoring
• & Endometrial Sampling
DISSEMINATION OF BENIGN DISEASE AFTER
MORCELLATION REQUIRING CYTOREDUCTIVE
SURGERY Obstet Gynecol 2014; Dec 5 online
3 CASES
• Symptoms 6-12 mo. Postop
• Abdominal Pain, GI & GU
Sx, Bowel Obstruction
• Masses & Widespread
Intraperitoneal Implants
on Imaging
• Required Exploratory
Laparotomy & Radical
Surgery
RESECTED SPLEEN &
THREE ATTACHED
“MORCELLOMAS”
BOTTOM LINE
• Morcellator Can Spread
Endometriosis, Benign
Leiomyomatous Tissue
• Looks Like Malignancy
• Serious Complication
• Requires Radical
Surgery and Extensive
Cytoreduction
LIVE BIRTH AFTER UTERINE TRANSPLANTATION
The Lancet 2014; (Oct 5): 6736(14):61728-1.
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BOTTOM LINE
• Infertility from congenital
absence of uterus or
previous hysterectomy
• Ethical issues immunosuppression
• Difficult Surgery  IVF
• 9 transplanted, 2 rejected
• 3 pregnancies so far
SURGICAL TECHNIQUE
PREVIEW OF THINGS TO COME
POINT-OF-CARE HANDHELD ULTRASOUND
SUPERIOR TO PHYSICAL
EXAM:
 First Year Medical
Students Outperformed
Board Certified
Cardiologists Using
Stethascope in
Diagnosing Cardiac
Abnormalities
 ? SAME FOR FUTURE
PELVIC & OB EXAMS
“POCKET” ULTRASOUND MACHINES
CONSIDERATIONS
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Cost ~ $8000 @ Present
Resistance From Radiology
Requires Training & Experience
“Incidentalomas”
Few Studies Yet to Prove Value
Medical Schools Already Incorporating
Probably Improve Diagnostic Skills
Physicians & Patients Like It
GOOD PATIENT CARE:
EVIDENCE BASED
MEDICINE IMPORTANT
BUT SO ARE:
 ACCESS
 COMPASSION
 COMMUNICATION
 CLINICAL JUDGEMENT
 COMMON SENSE