RECENTLY PUBLISHED PAPERS IMPORTANT TO YOUR PRACTICE RECENTLY PUBLISHED PAPERS IMPORTANT TO YOUR PRACTICE

JAMES R. SCOTT, MD

I have no conflict of interest to disclose.

OBJECTIVES OBJECTIVES

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 PRACTICEMY TOP STUDIES FOR 2014 THAT WILL AFFECT OR CHANGE YOUR PRACTICE

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 INITIATIVEJoint Commission, >50 National Medical SocietiesCHOOSING WISELY INITIATIVEJoint Commission, >50 National Medical Societies

PAPER/ABSTRACT/ DEFINITION OF

OVERUSE

DEFINITION OF OVERUSE

TESTS OR TREATMENTS

THAT PROVIDE NO

BENEFIT TO PATIENTS,

POTENTIALLY EXPOSING

THEM TO HARM

TRULY NECESSARY FREE FROM HARM NOT DUPLICATIVE SUPPORTED BY

EVIDENCEE

LAST YEAR ACOG LIST – PHYSICIANS SHOULD STOP DOING: LAST YEAR ACOG LIST – PHYSICIANS SHOULD STOP DOING:

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

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

HEADS UP: CURRENTLY UNDER CONSIDERATION FOR SECOND LISTHEADS UP: CURRENTLY UNDER CONSIDERATION FOR SECOND LIST

PROPHYLACTIC ANTIBIOTICS FOR CESAREAN Obstet Gynecol 2014;124(2):338.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 CLINICALLY IMPORTANT

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 “TIME OUT” CHECKLIST CHECK OUT YOUR HOSPITAL -

MONITORED BENCHMARK

AN ASIDE – RECENT FDA WARNINGS FOR ANTIBIOTICS TO KNOW ABOUTAN ASIDE – RECENT FDA WARNINGS FOR ANTIBIOTICS TO KNOW ABOUT

AZITHROMYCIN (ZITHROMAX) – Can Prolong QT Interval Arrhythmia & Death (rare)

FLOURIQUINOLONES Such as CIPROFLOXIN (CIPRO) Can Cause Acute Neuropathy

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 RATEIntrapartum Management Similar to Pt Without Previous Cesarean EXCEPT:

– Induction with Unripe Cervix

– Oxytocin Stimulation– Surveillance for

Uterine Rupture

UNIVERSITY OF UTAH UNIVERSITY OF UTAH

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 April 14, 2014

MEDIA: VBAC REFUSALS CUT OPTIONS The New York Times April 14, 2014

CASPER, WYO. – When Marie became pregnant again, she wanted a VBAC. But she quickly learned that the only full-service 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 MY VIEW

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 CESAREANObstet 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 GROWING CONSENSUS

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 ACCRETAINCREASING 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 STERILIZATIONAJOG 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 IMPLICATIONS: CONSIDER SALPINGECTOMY

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 TRANSPLANTATIONThe Lancet 2014; (Oct 5): 6736(14):61728-1.

• 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 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

NEJM 2014;370(12):1083s

“POCKET” ULTRASOUND MACHINES “POCKET” ULTRASOUND MACHINES

CONSIDERATIONSCONSIDERATIONS

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