Medical Monday: Obstetrics and Gynecology Weekly News Update

Good Monday. Here is you latest up to the minute installment of news and reports from the world of Ob/Gyn. 

A recently published article from the " Green" Journal of Obstetrics and Gynecology demonstrates that switching to from a private practice model to a laborist and certified nurse midwife model is associated with decreased C section rates and increased vaginal birth after C section rates. A laborist is an Ob Gyn who works on time shifts taking care of patients as they arrive on the labor unit, no matter whose patients they are. At this point we can only speculate as to why these findings are noted. We know Certified Nurse Midwives are trained to encourage patients in labor, which can help things go well, but good Obstetricians can, should and do often do this as well. We can also note that the shift work model takes away any sense of time pressure, which might be a factor. 

A recent article from the Journal of the American Academy of Orthopedic Surgeons states that "some radiologic imaging can be safe for pregnant women who have sustained traumatic injuries" . Obstetricians generally concur with this statement in the article as follows: "Women should be counseled that radiation exposure from a single diagnostic procedure does not result in harmful fetal effects." Regarding radiologic imaging during pregnancy, I was taught the simple common sense rule: if you need the procedure to take care of the mom, you need it to take care of the baby.

The Journal of the American Medical Association Surgery released an article that indicates one out of every 30 women who receive a synthetic vaginal mesh sling for urinary incontinence will suffer a complication requiring a second surgery. The article also notes the complications are far less frequent among surgeons perform mesh procedures regularly.

The US Preventive Services Task Force has done it again. A few days ago they released updated recommendations for the screening of pregnant women for iron deficiency anemia. By the way, this is a condition which we find very commonly in our population. They stated that " it is unsure whether pregnant woman who are asymptomatic for iron deficiency anemia should be screened for this condition or take iron supplements". They go on to explain that they cannot find "good or fair quality studies" on benefits or harms of the screening or supplementation and thus cannot recommend them. This is a terrific example of how the US Preventive Services Task Force comes to its conclusions. It is also a good illustration of how the recommendations can be grossly misconstrued. If there are no "good or fair quality studies" on the benefits or harms of testing for anemia or supplementing with iron, their conclusion is that, for the time being, neither should be done. An assumption is implicitly made  that their findings justify their conclusion, and it does not necessarily.  The lack of proper studies on the question may speak to the need for studies, or it may speak to the fact the there is a defacto professional consensus that research resources belong elsewhere than the question of anemia testing and supplementation. For of us who still do both prenatal care and deliveries, an arrangement which may not always be thus, it is common sense to want your patient to go into her labor with " a full tank". Yet among the nonclinical researchers at the USPSTF, there is no thought given to the fact that a large percentage of pregnant women are anemic and that a significant percentage of the same women have significant blood loss or an outright hemorrhage at or after the time of birth. In all fairness, when they take on a research question, they are looking to answer that specifically phrased question and that question only. In the course of publishing this recommendation, however, they have not given any consideration as to how the patient will fare at the time of her delivery if she goes into it anemic versus how she would do with a normal hematocrit. They are undoubtedly aware of this but they have not gone to any effort to make it clear to the reading public or the journalism community that they have not addressed this type of question or problem. They would likely be the first people to point out that they are not in a position to comment on how their recommendations would affect patient care in the long run. It is a shame that journalists and the general public do not come away with this more fleshed out picture. Instead doctors here and there are apt, if they do not read carefully, to quit testing for anemia and to quit supplementing with iron. Talk about missing the forest for the trees. 

The good news department has submitted the following : Babies born at extremely premature gestations such as 23 weeks has been found to have increasing survival rates, going from 27% to 33% between 2009 in 2012. There were increases for later gestational ages as well but these increases were less dramatic. Antenatal steroid administration to accelerate the development of lung maturity and decision to perform cesarean sections for extremely premature babies seem to be the most likely sources of improved survival.

Stay tuned for more medical news from the word of Ob/Gyn next week.