RECENTLY PUBLISHED PAPERSIMPORTANT TO YOUR PRACTICERECENTLY PUBLISHED PAPERSIMPORTANT TO YOUR PRACTICE

JAMES R. SCOTT, MD

I have no conflict of interest to disclose.

OBJECTIVESOBJECTIVES

TO BE FAMILIAR WITH PRACTICE CHANGING STUDIES IN PAST YEAR

TO ANTICIPATE INTENDED AND UNINTENDED CONSEQUENCES

TO APPLY THIS INFORMATIONIN YOUR OWN PRACTICE

MY TOP STUDIES FOR 2016-2017MY TOP STUDIES FOR 2016-2017

ONLY PRACTICAL NEW PAPERS FOR EVERYDAY PATIENT CARE

AVOIDED ABOG MOC ~ 1/2 OB & 1/2 GYN CHALLENGE: TO TRANSLATE

IMPERSONAL & DOGMATIC STATISTICS INTO INDIVIDUALIZED CARE OF REAL PEOPLE

CHOOSING WISELY INITIATIVEJoint Commission & >50 Medical SpecialtiesCHOOSING WISELY INITIATIVEJoint Commission & >50 Medical Specialties

PAPER/ABSTR

DEFINITION O OVERUSE

DEFINITION OF OVERUSE TESTS OR TREATMENTSTHAT PROVIDE NO BENEFIT TO PATIENTS, POTENTIALLY EXPOSINGTHEM TO HARM

TRULY NECESSARY FREE FROM HARM NOT DUPLICATIVE SUPPORTED BY

EVIDENCE

IN 2016 ACOG ADDED FIVE MORE THINGS PHYSICIANS SHOULD QUESTIONIN 2016 ACOG ADDED FIVE MORE THINGS PHYSICIANS SHOULD QUESTION

AVOID ROBOT FOR BENIGN GYN DISEASE WHEN CONVENTIONAL LAPAROSCOPIC OR VAGINAL APPROACH FEASIBLE

NO PRENATAL ULTRASOUNDS FOR NON-MEDICAL PURPOSES

DON’T ROUTINELY TRANSFUSE ASYMPTOMATIC PTS WITH HB > 7-8 GMS

DON’T DO ULTRASOUNDS TO SCREEN FOR OVARIAN CANCER

DON’T RECOMMEND BED REST DURING PREGNANCY FOR ANY INDICATION

ANTENATAL STEROIDS: COMPLETE COURSE vs PARTIAL vs NONE JAMA Pediatr 2016;170(12):1164-72.

ANTENATAL STEROIDS: COMPLETE COURSE vs PARTIAL vs NONE JAMA Pediatr 2016;170(12):1164-72.

INFANTS: 401-1000 grams; 22-27 weeks

DOSE DEPENDENT PROTECTIVE EFFECT ON DEATH AND NEURODEVELOPMENT IMPAIRMENT

BOTTOM LINE GIVE PROMPTLY TO

ALL PREMIES EVEN IF NOT TIME FOR COMPLETE COURSE

ONE 500 MG DOSE AZITHROMYCIN ADDED TO CEFAZOLIN PROPHYLAXIS FOR “NON ELECTIVE” CESAREANS NEJM 2016;375:1231-41.

ONE 500 MG DOSE AZITHROMYCIN ADDED TO CEFAZOLIN PROPHYLAXIS FOR “NON ELECTIVE” CESAREANS NEJM 2016;375:1231-41.

MULTICENTERED RCT CUT ENDOMETRITIS FROM

6.1% TO 3.8% NNT = 43 CUT WOUND INFECTIONS

FROM 6.6% TO 2.4% NNT = 24

CUT ALL INFECTIONS FROM 12.0% TO 6.1% NNT = 17

NO DIFFERENCE IN NEONATAL OUTCOMES

PRESENT REGIMEN PROVEN & SIMPLE– 1 GM IV OF CHEAPEST CEPHALOSPORIN

(Cefazolin) BEFORE SKIN INCISION FOR ALL HYSTERECTOMIES & CESAREANS

– 2 GM FOR OBESE PT – ADD 1 GM AT 3 HOURS or WITH >1500 ML

BLOOD LOSSMY TAKE

- SMALL OVERALL DIFFERENCE IN SERIOUSINFECTIONS – 2.9% vs 1.5%

- USE ONLY FOR LABOR, SROM- DO NO HARM - > 60% HOSPITAL PTS GET ANTIBIOTICS DRUG RESISTANCE, C. DIFF.

OPIOID EPIDEMIC – MOTHER AND INFANT DRUG DEPENDENCE INCREASE IN RURAL AREASOPIOID EPIDEMIC – MOTHER AND INFANT DRUG DEPENDENCE INCREASE IN RURAL AREAS

Rural and Urban differences in Neonatal Abstinence Syndrome and Maternal Opioid Use 2004-2013JAMA Pediatrics Online Nov 2016

BOTTOM LINE

Sevenfold Increase in Heroin and Opioid Use

LBW, Irritability, Seizures, Breathing, Eating & Sleeping Problems

42% in Utah & 35 % in Idaho of pregnant patients on Medicaid prescribed opioids

CARES ACT SIGNED INTO LAW JULY 2016$500 million for opioid addiction prevention and treatment programs

CARES ACT SIGNED INTO LAW JULY 2016$500 million for opioid addiction prevention and treatment programs

Increasing Death From Drug Overdose by State UTAH – Eligible for $9 million

WHAT CAN YOU DO?WHAT CAN YOU DO?

Be Aware of Increasing Problem in Pregnancy 80 % of Addiction Started with a Prescription

from a Physician – BE CAREFUL ! Check Out Comprehensive Addiction and

Recovery Act (CARA) and Services Available in Your Community

Funding Priority for Treatment Programs for Pregnant Women in Rural Areas

LAST YEARLAST YEAR

RCT WITH EXCELLENT STUDY DESIGN

GIVEN AFTER PREGNANCY DIAGNOSED

BOTTOM LINE: Vaginal micronized

Progesterone 400 mg daily did not result in higher live birth rate.

66% success with Txand 63% with placebo

CAVEAT – Did not address Tx during luteal phase STILL NEEDED

JUST PUBLISHEDFertil Steril 2017 (on line)JUST PUBLISHEDFertil Steril 2017 (on line)

Relatively inexpensive No harm Caution: Observational

cohort study CAVEAT – Usual live birth

rate with no Tx is 60-70% Need RCT With Placebo

Matched Controls To Prove

Pts with elevated nCycline Treated with vaginal micronized progesterone (Prometrium or Endometrin) q 12 hrbeginning 3 days after LH surge x 10 wks

Pregnancy success: 68% vs 51% in untreated

ADVANTAGES OF TRANSFERRING A SINGLE EMBRYO IN ART PATIENTS Fertil Steril 2015;106(5):1107-14.

ADVANTAGES OF TRANSFERRING A SINGLE EMBRYO IN ART PATIENTS Fertil Steril 2015;106(5):1107-14.

LIVE BIRTH RATE Single embryo vs Double

embryo transfer = 46.0%vs 46.9%

Reduces Rate of Twins, Triplets, Prematurity, Perinatal Morbidity

COSTS: Delivery1 Year Singleton - $21,500 Twins - $105,00 Triplets - $400,00

LIVE BIRTH RATE AND MULTIPLE BIRTH RATE BY PERCENT OF SINGLE EMBRYO TRANSFERS FOR FRESH IVF CYCLES IN PATIENTS < 35 YRS

LIVE BIRTH RATE AND MULTIPLE BIRTH RATE BY PERCENT OF SINGLE EMBRYO TRANSFERS FOR FRESH IVF CYCLES IN PATIENTS < 35 YRS

Useful facts for referring physician (you) and patients to have.

Is slightly higher pregnancy rate worth risk of much higher multiple birth rate?

FERTILITY PRESERVATION IN YOUNG WOMEN –CHEMOTHERAPY OR RADIATION Tx FOR CANCER

Hum Reprod 2017;32(1):154-64.

FERTILITY PRESERVATION IN YOUNG WOMEN –CHEMOTHERAPY OR RADIATION Tx FOR CANCER

Hum Reprod 2017;32(1):154-64.

53 YOUNG WOMEN WITH CANCER HAD OVARIAN TISSUE FROZEN BEFORE STARTING TREATMENT

TRANSPLANTED BACK IN 32 WHO WANTED PREGNANCY

18 PREGNANCIES WITH 15 CHILDREN

CHEMOTHERAPY & BONE MARROW TRANSPLANT FOR BETA THALASSEMIA @ AGE 9 RIGHT OVARY REMOVED IN ADVANCE AND FROZEN

CHEMOTHERAPY & BONE MARROW TRANSPLANT FOR BETA THALASSEMIA @ AGE 9 RIGHT OVARY REMOVED IN ADVANCE AND FROZEN

STRIPS OF THAWED OVARY TRANSPLANTED 15 YRS LATER ONTO FAILED LEFT OVARY

BEGAN OVULATING RETRIEVED 8 EGGS

FOR IVF IMPLANTED 2 EMBRYOS PREGNANCY

> 60 WOMEN WITH BABIES FROM THIS TECHNIQUE NOW

OBSTET GYNECOL 2016;128(6):1215.OBSTET GYNECOL 2016;128(6):1215.

500 U.S. Hospitals Parallels Increase in

Cesareans & AccretaBOTTOM LINE Be Prepared Simulation, Training,

Emergency Plan Refer - Transfer

31 yr old G-6 P-5 (2 prior C/S) referred for fetal cardiac anomaly & Placenta Previa

Admitted for scheduled repeat C/S @ 34 wks Two days before SROM & severe vag bleeding Rapid Shock O.R. Percreta C/HYST Uncontrollable Hemorrhage 100 u blood Death on Table

30 people including experienced MFMs, OB Anethesiologists, Gyn Oncologist, C-V Surgeon

CASE – U OF IOWA 6 WEEKS AGOCASE – U OF IOWA 6 WEEKS AGO

AVAILABLE THROUGH ACOGAVAILABLE THROUGH ACOG

UNEXPECTED PERCRETA - WHAT DO I DO NOW? Discovered Before Delivery Discovered After DeliveryUNEXPECTED PERCRETA - WHAT DO I DO NOW? Discovered Before Delivery Discovered After Delivery

DON’T FORGET THE UMBRELLA PACKDON’T FORGET THE UMBRELLA PACK

Dildy GA, Scott JR, Saffer CS, Belfort MA. An Effective Pack for Severe Pelvic Hemorrhage. Obstet Gynecol2006;108:1222-6.

PREVIEW OF THINGS TO COME:POSSIBLE DRUGLESS ANSWER TO POSTPARTUM HEMORRHAGE

PREVIEW OF THINGS TO COME:POSSIBLE DRUGLESS ANSWER TO POSTPARTUM HEMORRHAGE

BOTTOM LINE SURFACE ELECTRODE

CLIPS ON EAR STIMULATES NEURAL

CIRCUITS MODULATES VASCULAR & CLOTTING MECHANISMS

RAPIDLY REDUCES BLEEDING BY 40-50%* In Collaboration with Bill GatesThe Global Good Fund

CASE: 19-YR-OLD PRESENTS WITH FEVER, PROGRESSIVE AGITATION, IRRITABILITY, HALLUCINATIONS & DECREASING CONSCIOUSNESS. EXTENSIVE WORKUP NEGATIVE. PELVIC ULTRASOUND SHOWS A 2-3 CM OVARIAN MASS CONSISTENT WITH A DERMOID.

CASE: 19-YR-OLD PRESENTS WITH FEVER, PROGRESSIVE AGITATION, IRRITABILITY, HALLUCINATIONS & DECREASING CONSCIOUSNESS. EXTENSIVE WORKUP NEGATIVE. PELVIC ULTRASOUND SHOWS A 2-3 CM OVARIAN MASS CONSISTENT WITH A DERMOID.

What does she have?

What would you do?

DERMOID CYST & ENCEPHALOPATHYBJOG 2017;124:337-41.DERMOID CYST & ENCEPHALOPATHYBJOG 2017;124:337-41.

Life threatening Get stat anti-NMDA blood

and CSF antibodies May need MRI to diagnose

very small (< 1 cm) dermoid Early & complete removal

of dermoid (Cystectomy or oophorectomy)

Intraoperative ultrasound and bivalve other ovary

ANTI-N-METHYL-D-ASPARTATE (NMDAr)RECEPTOR ENCEPHALITISANTI-N-METHYL-D-ASPARTATE (NMDAr)RECEPTOR ENCEPHALITIS

First recognized in 2005 > 500 cases in literature but only 10% in

OB/GYN literature Most common in young women Flu-like symptoms rapid onset of bizarre

neurologic and psychotic behavior CSF anti-NMDA antibodies diagnostic Removal of dermoid – Rapid improvement

in majority

THIS YEAR’S EPIDEMIOLOGY STUDY AND THE MEDIA THIS YEAR’S EPIDEMIOLOGY STUDY AND THE MEDIA

Found increased risk for behavioral problems age 7

Relied on maternal recall Raises possibilities of bias

and misclassification Confounding by indication

also a concern All associations modest with

relative risks 1.4 or less Other studies with

conflicting results No Observational Study

Can Prove Causation

Many pitfalls - “Garbage in, Garbage out” Phenomenon Unreliable Databases Data Dredging Inadequate Control For Confounding Factors Weak Associations MISLEADING & CAUSE UNNECESSARY ALARM

PREMISE: PURPOSE OF MEDICAL JOURNAL RESEARCHARTICLES IS TO IMPROVE PATIENT CARE

PREMISE: PURPOSE OF MEDICAL JOURNAL RESEARCHARTICLES IS TO IMPROVE PATIENT CARE

SHOULD BE USEFUL TO PHYSICIANS VALID RESULTS CLINICALLY RELEVANT CONCISE

INSTEAD - ERA OF INFORMATION OVERLOAD AND SOCIAL MEDIA INSTEAD - ERA OF INFORMATION OVERLOAD AND SOCIAL MEDIA

CHANGING SCENE FOR KEEPING UP WITH THE OB/GYN LITERATURECHANGING SCENE FOR KEEPING UP WITH THE OB/GYN LITERATURE

RELIABLE AND USEFUL SOURCES – BE EFFICIENT GREEN & GRAY JOURNAL (Libraries – Online Only) UP TO DATE www.uptodate.com ACOG PRACTICE BULLETINS www.acog.org ABOG MOC PROGRAM www.abog.org INDIVIDUALIZED LITERATURE SEARCHES

EXAMPLE OF FREE AUTOMATIC SEARCHESBASED ON YOUR PRACTICE AND INTERESTS

pubcrawler.gen.tcd.ie Resources@acog.org

EXAMPLE OF FREE AUTOMATIC SEARCHESBASED ON YOUR PRACTICE AND INTERESTS

pubcrawler.gen.tcd.ie Resources@acog.org

GOOD PATIENT CARE:

EVIDENCE BASED MEDICINE IMPORTANTBUT SO ARE:

COMPASSION COMMUNICATION CLINICAL JUDGEMENT COMMON SENSE