Clinical Health Updates

Misoprostol = PGE2 for induction of labor at term with unfavorable cervix

Clinical Question:
How do misoprostol and prostaglandin E2 compare for induction of labor for women at term with an unfavorable cervix?

Bottom Line:
Although misoprostol in women at term with an unfavourable cervix and intact membranes was more effective than PgE2 in achieving vaginal delivery within 24 hours, misoprostol does not reduce the rate of caesarean delivery either in all women or in the subgroup of nulliparous women, and it increases the rates of tachysystole and hyperstimulation. Further studies of misoprostol using a starting dose of 25 microgram may be warranted.

Reference:
Crane JM, Butler B, Young DC, Hannah ME. Misoprostol compared with prostaglandin E2 for labour induction in women at term with intact membranes and unfavourable cervix: a systematic review. BJOG 2006;113:1366-1376.

Study Design:
Meta-analysis (randomized controlled trials)

Synopsis:
Misoprostol is a commonly used prostaglandin to induce labour. A potential risk of induction, however, is caesarean delivery, especially in women with an unfavourable cervix. The authors evaluated the use of misoprostol, compared with prostaglandin E2 (PgE2), for labour induction in women at term with an unfavourable cervix and intact membranes. PubMed, Medline, EMBASE and the Cochrane Library were searched for articles published in any language from January 1987 to December 2005, using the keywords ‘misoprostol’, ‘labour/labor’ and ‘induction’. They identified randomised trials of women at term (> or =37 weeks of gestation) with intact membranes and unfavourable cervix, undergoing labour induction with misoprostol, orally, vaginally, sublingually or buccally, compared with PgE2 vaginally or intracervically. Caesarean delivery was the primary outcome, with tachysystole and hyperstimulation as secondary outcomes. The primary analysis compared any misoprostol with any PgE2 for all women, with a subgroup analysis for nulliparous women. Secondary analyses compared different routes and doses of misoprostol (oral or vaginal and 25 microgram or >25 microgram) and PgE2 (intracervical or vaginal). Relative risks (RR) and 95% confidence intervals (CI) were calculated using random effects models.Main results Fourteen of 611 articles identified met the criteria for systematic review, with three providing information for nulliparous women. There was no difference in the risk of caesarean delivery between misoprostol and PgE2 groups (RR = 0.99, 95% CI = 0.83-1.17). Any misoprostol was associated with higher risks of tachysystole and hyperstimulation compared with any PgE2 (RR = 1.86, 95% CI = 1.01-3.43 and RR = 3.71, 95% CI = 2.00-6.88, respectively). There was a higher rate of vaginal delivery within 24 hours among all vaginal deliveries with any misoprostol compared with any PgE2 (RR = 1.14, 95% CI = 1.00-1.31), and among all deliveries, a lower rate of oxytocin use (RR = 0.71, 95% CI = 0.60-0.85) but a trend towards increased meconium staining was observed (RR = 1.22, 95% CI = 0.96-1.55). The use of misoprostol at starting dosages >25 microgram had similar findings to the primary analysis. Studies of lower misoprostol dosing (starting dose of 25 microgram) did not show any differences in the outcomes of interest, but the sample size of this secondary analysis was small (304 women, 155 receiving misoprostol).

Elective cesarean does not preserve anal continence

Clinical Question:
Can an elective cesarean delivery avoid maternal pelvic trauma and preserve anal continence?

Bottom Line:
The best evidence to assess the efficacy of cesarean section in the prevention of anal incontinence would be in randomized trials of average-risk pregnancies with few crossovers. In the absence of such trials and based on this review, cesarean section does not prevent anal incontinence. This implies that incontinence associated with delivery may be more likely incontinence caused by pregnancy.

Reference:
Nelson RL, Westercamp M, Furner SE. A systematic review of the efficacy of cesarean section in the preservation of anal continence. Dis Colon Rectum 2006;49:1587-1595.

Study Design:
Systematic review

Synopsis:
Elective primary cesarean section is performed largely to avoid maternal pelvic trauma that may result in anal incontinence, although its efficacy in this regard has not been thoroughly assessed. The authors performed a systematic review of published reports that compare anal incontinence risk by mode of delivery. PubMed was searched from 1966 through August 2005. Authors were contacted for missing data or analyses. Both randomized and nonrandomized reports were included. Eligible studies included females having vaginal delivery or cesarean section, fecal and/or flatal incontinence was reported as an outcome, and risk was calculable from the reported data. Crude data were extracted from the reports, as well as reported odds ratios and confidence intervals. In the nonrandomized studies, adjusted odds ratios also were extracted and additional data obtained from authors to adjust risks for age and parity if not originally done. Sensitivity analyses were performed using quality indicators: age and parity adjustment, time to continence assessment, and mode of previous delivery. Fifteen studies were found eligible, encompassing 3,010 cesarean sections and 11,440 vaginal deliveries. The summary relative risk for fecal incontinence was 0.91 (95 percent confidence interval, 0.74-1.14). For flatus the relative risk was 0.98 (range, 0.86-1.13). The number needed to treat by cesarean section was 167 to prevent a single case of fecal incontinence. Five studies were judged to be of high quality. In these studies, the summary relative risk was 0.94 (range, 0.72-1.22) and number needed to treat was 198.

Steroids effective for hyperemesis gravidarum

Clinical Question:
In pregnant women hospitalized for intractable hyperemesis gravidarum, is high-dose hydrocortisone more effective than metoclopramide in reducing the rate of vomiting?

Bottom Line:
A short course of hydrocortisone is an effective treatment for intractable hyperemesis gravidarum. Intravenous hydrocortisone 300 mg daily will decrease the episodes of vomiting in women hospitalized with hyperemesis of pregnancy to an extent similar or greater than that of metoclopramide (Reglan).

Reference:
Bondok RS, El Sharnouby NM, Eid HE, Abd Elmaksoud AM. Pulsed steroid therapy is an effective treatment for intractable hyperemesis gravidarum. Crit Care Med 2006;34:2781-2783.

Study Design:
Randomized controlled trial (double-blinded)

Synopsis:
Intractable hyperemesis gravidarum remains a serious cause of morbidity among pregnant women. If not controlled, hyperemesis gravidarum can lead to severe disability, electrolyte and acid base imbalance, and even various organ system dysfunctions. From the successful use of steroids for chemotherapy-induced emesis, corticosteroids might prove useful in hyperemesis gravidarum. The authors compared the efficacy of pulsed hydrocortisone therapy with that of metoclopramide for the management of intractable hyperemesis gravidarum. They did a prospective, double-blind study at intensive care unit of Ain Shams University Maternity Hospital. Forty patients aged 19-34 yrs having a normal appearing intrauterine pregnancy, of < or =16 wks gestation, admitted to the intensive care unit with intractable hyperemesis meeting the study criteria. Patients were randomly assigned to receive either intravenous hydrocortisone 300 mg as a daily dose or intravenous metoclopramide 10 mg 3 times daily. After 3 days the hydrocortisone was tapered completely during the course of 1 wk, whereas the metoclopramide was continued without change for 1 wk. Patients were followed up daily during the therapy course and for 2 wks following intensive care unit discharge. There was a significant reduction in vomiting episodes in the hydrocortisone group compared with the metoclopramide group (p < .0001). Within-patient analyses showed a significant reduction in mean vomiting episodes in the hydrocortisone group within the first 3 days (p < .0001). No patients from the hydrocortisone group but six of the patients receiving metoclopramide were readmitted for intractable vomiting within 1 wk from discharge. Five of them showed improvement on intravenous hydrocortisone therapy.

Counseling helps fearful women choose vaginal delivery

Clinical Question:
Can crisis-oriented counseling change a women’s requests for cesarean delivery associated with fear of childbirth?

Bottom Line:
Impending birth activates previous traumatic experiences, abuse, and psychiatric disorders that may give rise to fear of vaginal birth. When women were referred to a specialist service for fear of birth and request for cesarean, they became conscious of, and to some degree worked through, the causes of their fear, and most preferred vaginal birth. They remained pleased with their choice later.

Reference:
Nerum H, Halvorsen L, Sorlie T, Oian P. Maternal request for cesarean section due to fear of childbirth: can it be changed through crisis-oriented counseling? Birth 2006;33:221-225.

Synopsis:
A psychosocial team was established to meet the needs of an increasing number of pregnant women referred for fear of birth who wished a planned cesarean. This study describes the intervention, the women’s psychosocial problems in relation to degree of fear of birth, changes in their wishes for mode of birth and birth outcome, women’s satisfaction with the intervention, and their wishes for future births. The study sample comprised 86 pregnant women with fear of birth and a request for planned cesarean, who were referred for counseling by a psychosocial team at the University Hospital of North Norway in the period 2000-2002. Data were gathered from referral letters, from antenatal and intrapartum care records, and from a follow-up survey conducted 2 to 4 years after the birth in question. Fear of birth was accompanied by extensive psychosocial problems in most women. Ninety percent had experienced anxiety or depression, 43 percent had eating disturbances, and 63 percent had been subjected to abuse. Twenty-four percent of those with psychiatric conditions had previously been in treatment. After the intervention, 86 percent changed their original request for cesarean section and were prepared to give birth vaginally. The follow-up survey confirmed long-term satisfaction with having changed their request for a cesarean delivery. Of these, 69 percent gave birth vaginally and 31 percent were delivered by cesarean for obstetrical indications.

Intercourse doesn’t hasten onset of labor

Clinical Question:
Is sexual intercourse at term pregnancy associated with earlier labor and delivery?

Bottom Line:
Sexual intercourse at term is not associated with ripening of the cervix and does not hasten labor. LEVEL OF EVIDENCE: II-3.

Reference:
Schaffir J. Sexual intercourse at term and onset of labor. Obstet Gynecol 2006;107:1310-1314.

Study Design:
Cohort (prospective)

Synopsis:
This cohort of 93 women with low-risk singleton pregnancies at 37 or more weeks’ gestation was asked at weekly prenatal visits if they had engaged in penile-vaginal intercourse during the past week, and if so, how many times. Women were excluded from the study if they had contraindications to vaginal intercourse for maternal or fetal reasons. Cervical examination was performed at the time of each visit and a Bishop score was recorded. Half of the women (n = 47) reported sexual intercourse at any time during or after her 37th week of gestation, and were defined as sexually active. Reported demographic parameters and parity did not differ between sexually active women and those who abstained, although race was not reported. Mean gestational age at delivery was 39.9 weeks (+/- 0.9 weeks) for sexually active women and 39.3 weeks (+/- 0.9 weeks) for abstaining women, which was statistically significant (P = .001). There were fewer inductions of labor in the abstaining group (5/46 vs 12/47; NS). Most of these inductions were elective at the patient’s request. Correspondingly, there was no increase in Bishop score in sexually active women. The study was too small to analyze the data on the basis of frequency of intercourse, but the results did not suggest that more frequent intercourse would change the study conclusions. There were no apparent complications observed for the women who chose to have intercourse at term pregnancy.

Multiple cesareans increase risk of maternal morbidity

Clinical Question:
For women undergoing cesarean delivery without labor, does the number of prior cesareans influence the risk of maternal morbidiity?

Bottom Line:
Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2.

Reference:
Silver RM, Landon MB, Rouse DJ, et al, for the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean sections. Obstet Gynecol 2006;107:1226-1232.

Study Design:
Cohort (prospective)

Synopsis:
Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. The authors did a prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

Haloperidol shortens duration, intensity but not frequency of post-op delirium

Clinical Question:
Does perioperative haloperidol (Haldol) prevent delirium in elderly patients undergoing hip surgery?

Bottom Line:
Low-dose haloperidol prophylactic treatment demonstrated no efficacy in reducing the incidence of postoperative delirium. It did have a positive effect on the severity and duration of delirium. Moreover, haloperidol reduced the number of days patients stayed in the hospital, and the therapy was well tolerated.

Reference:
Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005;53:1658-66.

Study Design:
Randomized controlled trial (double-blinded)

Synopsis:
To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium. Randomized, double-blind, placebo-controlled trial was done. Large medical school-affiliated general hospital in Alkmaar, the Netherlands. A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium. Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients. The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay. The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk=0.91, 95% confidence interval (CI)=0.6-1.3); the mean highest DRS-R-98 score+/-standard deviation was 14.4+/-3.4 and 18.4+/-4.3, respectively (mean difference 4.0, 95% CI=2.0-5.8; P<.001); delirium duration was 5.4 versus 11.8 days, respectively (mean difference 6.4 days, 95% CI=4.0-8.0; P<.001); and the mean number of days in the hospital was 17.1+/-11.1 and 22.6+/-16.7, respectively (mean difference 5.5 days, 95% CI=1.4-2.3; P<.001). No haloperidol-related side effects were noted.