How to identify the uterosacral ligament…and more
“IN THE FIRST 5 MIN OF LIFE: OB AND NEONATAL MEDICINE PRACTICES ARE EVOLVING—IN WAYS THAT MAY SURPRISE YOU”
ROBERT L. BARBIERI, MD
(EDITORIAL; JUNE 2011)
Many benefits to delayed cord clamping
Delayed cord clamping is a reasonable practice because the baby is coming off “bypass,” so to speak. It is especially useful as an adjunct to skin stimulation in newborns who have tight cords or poor thoracic skin capillary flow. Once the color returns, the cord may be clamped.
Michael Linzey, MD
Orange, Calif
Midwives adopted these neonatal practices long ago
Midwives have delayed cord clamping and abstained from bulb-syringe suctioning of all newborns for at least 23 years.
Kathryn Newburn, CNM, RNP
Burlingame, Calif
Dr. Barbieri responds:Delayed clamping is regaining prominence
I appreciate Dr. Linzey’s view on the benefits of delayed cord clamping. Ms. Newburn makes the important observation that midwives are leaders in birthing practices. As I noted in my editorial, the practice of delayed cord clamping was advocated by leading obstetricians from the 1930s through the 1960s.1,2 The practice waned, but is now likely to be resurrected.
“A TALK ABOUT, THEN A PLAN FOR, ANTIDEPRESSANTS IN PREGNANCY”
DANIELLE CARLIN, MD, AND LOUANN BRIZENDINE, MD (MAY 2011)
Why was bupropion ‘downgraded’ to Pregnancy Category C?
In the past, bupropion (Wellbutrin) was a Pregnancy Category B drug and remained so long after the serotonin reuptake inhibitors (SRIs) were changed to Pregnancy Category C (Category D in the case of paroxetine [Paxil]). Many of my OB colleagues, therefore, began using bupropion. Why is the drug now considered “suspect”?
What other antidepressants would you consider using in pregnancy besides SRIs, if any?
Jonathan A. Fisch, MD
Indianapolis, Ind
Dr. Brizendine responds:We need more information on bupropion
Bupropion was moved from Pregnancy Category B to Category C because of the dearth of information about its effects in human pregnancy. According to a recent study, bupropion was used in the United States by 0.7% of women during pregnancy (the rate for SRIs was 3.8%).1
Bupropion does not cross the placenta, but its major metabolite, OH-bupropion, does. Neither bupropion nor its metabolite affect placental tissue viability or functional parameters, according to a recent study.2
As for first-trimester malformations, a recent Canadian study of 1,856 women (928 taking antidepressants and 928 in a comparison group) found 30 (3.2%) malformations among the group of women taking antidepressants, compared with 31 (3.3%) in the control group. The antidepressants taken by women in this analysis included bupropion (113), citalopram (184), escitalopram (21), fluvoxamine (52), nefazodone (49), paroxetine (148), mirtazepine (68), fluoxetine (61), trazodone (17), venlafaxine (154), and sertraline (61). None of these antidepressants were associated with an increased risk of major malformations above baseline. Only venlafaxine and paroxetine—but not bupropion—have been associated with an increased rate of spontaneous abortion.3
The bottom line on bupropion in pregnancy? We need more information, but so far it has not been associated with an increased incidence of malformation or spontaneous abortion in humans.
“IS THE ANNUAL PELVIC EXAM A RELIC OR A REQUISITE?”
BARBARA S. LEVY, MD (APRIL 2011)
Routine pelvic examination should include ultrasonography (US)
The stethoscope was invented in 1816 by a French physician, René-Théophile-Hyacinthe Laënnec. By amplifying cardiac and pulmonary sounds, he revolutionized evaluation of the heart and lungs. Until then, these organs were assessed by directly applying one’s ear to the patient’s chest.1
When it comes to the bimanual pelvic exam, our specialty remains in the early 19th century, trying to discern between the two hands what is going on in the pelvis. A symptomatic patient will be referred for imaging regardless of the findings of this exam, but early pathology might be missed in an asymptomatic patient.2
The time has come to adopt US-assisted pelvic examination as routine. With some practice, this modality will prolong the office visit only minimally and save time and money overall.
In symptomatic patients, US-assisted pelvic examination can provide an immediate diagnosis in many cases, without the need for time-consuming and expensive referrals. The patient will have less anxiety and miss less time from work. An immediate diagnosis also reduces the number of telephone calls that need to be made.3
In asymptomatic patients, the detection of early pathology—be it an ovarian cyst, thickened endometrium, free fluid in the pelvis, or another pathology—will allow the physician to establish an early follow-up plan, improve management, and, in some cases, save lives.4,5
Some critics of this approach argue that the financial cost is excessive. However, I believe that endovaginal US, like the stethoscope, should be incorporated into the routine examination at no extra charge to the patient. In view of the large potential savings achieved by avoiding US referrals and extra office visits, I believe the insurance companies should consider subsidizing the equipment and accept a new code for US-assisted pelvic examination. It would be a win-win proposition for the health-care system, our patients, and the specialty.
Michael Harel, MD
New York, NY
Dr. Levy responds:Routine ultrasonography increases costs
If transvaginal US were added to the routine pelvic examination, as Dr. Harel proposes, there is no doubt that the US probe would find cysts, fluid, and thickened endometrium in asymptomatic women. For symptomatic women, office-based transvaginal US in the hands of well-trained and experienced providers does enable rapid diagnosis and treatment. We have no idea, however, what the appropriate management or follow-up should be for asymptomatic women who have endometrial thickening (how much is too much and at what age?), fluid in the pelvis, or ovarian cysts (see the excellent four-part series on defining “normal” ovaries, by Ilan E. Timor-Tritsch, MD, and Steven R. Goldstein, MD, which appeared last year in OBG Management1-4 and is available in the archive at obgmanagement.com). Far from reassuring our patients, these findings with uncertain clinical significance will undoubtedly create anxiety among the “worried well” and their providers.
