Opening Day Isn’t an Indication for Cesarean Delivery

Image: ©iStock/ryan_christensen

A sportscaster was sharply criticized for suggesting that a baseball player’s pregnant wife should have opted for  “elective” cesarean delivery before the start of baseball season so that her husband would not miss playing on opening day. Image: ©iStock/ryan_christensen

Although one doesn’t expect hear the phrases “C-section” and baseball season “opening day” in the same breath, that’s what happened last week when sportscaster Boomer Esiason criticized New York Mets second baseman Daniel Murphy on Esiason’s morning radio show for Murphy’s decision to miss the first 2 games of the regular season to be with his wife and newborn son. And when Esiason suggested that the couple should have opted for “elective” cesarean delivery of their son before the season started, it triggered an avalanche of criticism for his remark and sparked discussions about paternity leave and the potential risks of elective cesarean delivery.

According to the Centers for Disease Control and Prevention, 1 of 3 births in the United States is a cesarean delivery. However, elective cesarean delivery, which is performed before the onset of natural labor based on the mother’s request, is a small fraction of overall births. Because there are no medical reasons for performing this surgery, there also are no clear-cut health benefits for either mother or newborn.

In contrast, medically indicated cesarean deliveries are performed to benefit the health of the mother or baby, primarily because of placental abnormalities (such as placenta previa, in which the placenta covers all or part of the opening of the cervix) or the position of the fetus (such as a breech presentation, in which the infant’s feet or buttocks enter the birth canal first rather than the head). Pregnant women with genital herpes simplex infection who have active lesions or women with HIV infection who have high levels of the virus in their bodies also are advised to undergo the procedure to prevent transmitting the infection to the infant during childbirth. In addition, women who have had a previous cesarean delivery are often advised to undergo the procedure with subsequent births.

“We do [cesarean delivery] all the time for breech babies,” explains Caren Stalburg, MD, clinical assistant professor of obstetrics and gynecology at the University of Michigan. But obstetricians also see patients who feel they have compelling reasons for requesting the procedure on an elective basis. Stalburg says that when a woman requests a cesarean delivery, she begins a discussion early and tries to understand the patient’s reasons, such as worries about tears in the perineum, the area between the vagina and anus. “I explore the topic and massage all of the reasons. Is she afraid of the birth process? Is she worried about her perineum?”

Stalburg has coined what she calls the “6 Cs of elective cesarean delivery: clarification of request, comorbidities (other health conditions) in the mother, number of children planned, consent, correct gestational age, and confirmation of insurance coverage. These 6 Cs provide a useful framework for decision making about elective cesarean sections. “The discussion is very different in a 21-year-old having her first child vs a 40-year-old having her only child,” explains Stalburg, who notes that the risk of surgical complications and subsequent placental abnormalities increase with each additional cesarean delivery.

As with any medical procedure, the risks and benefits of planned cesarean delivery should be considered. In addition to convenience, a concern about pelvic floor dysfunction (which occurs when the muscles in the pelvic area are weakened or injured, resulting in problems such as urinary incontinence) is frequently cited as a reason for opting for the procedure on an elective basis. But “risk of pelvic floor dysfunction shouldn’t be the only reason to have an elective section,” says Stalburg, who notes that although the incidence is lower with cesarean delivery, some risk remains. On the risk side of the equation, the procedure involves an increased likelihood of breastfeeding difficulties, postoperative pain, longer recovery time, and wound infection.

Risks of elective cesarean delivery also extend to the newborn. For example, uncertainty surrounding gestational age can result in prematurely delivering an infant thought to be full term. Stalburg explains that infants have an increased risk of respiratory difficulties if they are delivered before 39 weeks of gestation, so it’s important to confirm gestational age.

Regarding insurance coverage, some carriers may not provide full coverage for elective cesarean delivery. Stalburg advises all of her patients to discuss potential restrictions with their insurance company.

Finally, social issues frequently play a role in the birth process. For example, Stalburg has cared for patients whose husbands were going to be deployed on a particular date. “Although elective C-section is an option, scheduled induction of birth may be another option,” says Stalburg, who adds that a woman’s recovery after an uncomplicated vaginal birth is generally faster than after cesarean delivery.

Stalburg says it is essential that women who feel they have compelling reasons for requesting an elective cesarean delivery understand the ramifications.

“If she has made an informed choice and has a good understanding of the risks and benefits, and if after multiple discussions and visits, she decides this is the best option for her and her baby, I feel ethically comfortable with the option,” says Stalburg.

***

For additional information:

Ecker, J. Elective cesarean delivery on maternal request. JAMA. 2013:309[18]:1930-1936.

 

Higher Vitamin D Levels at Time of Breast Cancer Diagnosis Associated with Better Survival

Higher serum vitamin D levels may be associated with longer survival for women with breast cancer. (Image: mark wragg/iStock.com)

Higher serum vitamin D levels may be associated with longer survival for women with breast cancer. (Image: mark wragg/iStock.com)

Higher blood levels of vitamin D may be associated with improved survival from breast cancer, suggest new findings from study published this week in Anticancer Research.

The study, a meta-analysis of 5 studies of vitamin D (25-hydroxyvitamin D) serum concentrations obtained at the time of breast cancer diagnosis, involved a total of 4443 women who were followed-up for an average of 9 years. The women were divided into quintiles of vitamin D serum concentrations. Women in the highest vitamin D quintile (an average of 30 ng/mL) were about half as likely to die of breast cancer during the follow-up period as those in the lowest quintile (an average of 17 ng/mL), the researchers found.

There’s a biologically plausible mechanism for vitamin D’s apparent beneficial effect on breast cancer survival, the authors suggest. “Vitamin D metabolites increase communication between cells by switching on a protein that blocks aggressive cell division,” said Cedric F. Garland, DrPH, a coauthor of the study and professor in the department of Family and Preventive Medicine, University of California, San Diego School of Medicine, in a statement. As long as vitamin D receptors are present on the tumor cells (where they remain until the tumor is advanced), “tumor growth is prevented and kept from expanding its blood supply,” he explained. “This is the reason for better survival in patients whose vitamin D blood levels are high.”

Although the researchers did not study whether adding vitamin D supplements to the diet of women diagnosed with breast cancer improved survival, they did recommend such supplementation to get serum vitamin D levels into the normal range, which is between 30 ng/mL and 74 ng/mL.

Breast cancer is the most common cancer in women worldwide, with about 1.7 million new cases and a half million deaths reported in 2012. In the United States, about 234 600 new cases and about 40 000 deaths from breast cancer were reported in 2013.

Malnutrition May Interfere With HIV Treatment in Pregnant and Breastfeeding Women

   To protect child health, public health authorities in Uganda must combat both malnutrition and mother-to-child transmission of HIV.  Image: JAMA, ©AMA

To protect child health, public health authorities in Uganda must combat both malnutrition and mother-to-child transmission of HIV. Image: JAMA, ©AMA

Malnutrition may reduce levels of human immunodeficiency virus (HIV) medications in pregnant or breastfeeding women, which may hamper efforts to prevent mother-to-child transmission, according to a study published today in the The Journal of Clinical Pharmacology.

Maternal infections with HIV in sub-Saharan Africa present a pressing public health concern, with as many as 40% of pregnant women infected, according to the study authors. Antiretroviral treatment during pregnancy and breastfeeding can substantially reduce the risk that these mothers will pass the virus to their newborns, so many governments and aid organizations have emphasized maternal treatment as a way to curb transmission. The new findings bolster previous evidence demonstrating the importance of addressing malnutrition simultaneously with drug treatment.

Imke H. Bartelink, PharmD, of the University of California, San Francisco, and colleagues from the United States and Uganda found that malnutrition may complicate efforts to reduce mother-to-child transmission through antiretroviral treatment. The study involved 225 Ugandan women who were being treated for HIV infection. Many were malnourished; 80% reported lacking adequate food for their families, 50% reported moderate to severe hunger, and 26% lost weight during pregnancy.

The researchers analyzed blood spots and hair samples from the women for lopinavir, ritonavir, and efavirenz levels. They found that drug levels were substantially reduced in malnourished study participants compared with well-nourished participants, with a decrease in exposure of 33% for lopinavir, 15% for efavirenz, and 17% for ritonavir. As expected, they also found that during pregnancy the body clears lopinavir and ritonavir more quickly, something that clinicians account for when dosing pregnant women.

Previous studies also have suggested that malnutrition may reduce the likelihood that patients taking antiretroviral medication will take them as prescribed, without skipping doses. Bartelink and colleagues used the samples as a means to verify whether the adherence rates that patients reported were accurate, and confirmed that such testing can be a useful tool in helping to verify adherence.

Author Insights: Two Doses of HPV Vaccine Reduce Genital Wart Risk

Lisen Arnheim-Dahlström, PhD, of the Karolinska Institutet in Stockholm, Sweden, and her colleagues provide evidence that 1 or 2 doses of the human papillomavirus vaccine may provide some protection against the development of genital warts. Image: Karolinska Institutet

Lisen Arnheim-Dahlström, PhD, of the Karolinska Institutet, and her colleagues found that 1 or 2 doses of the human papillomavirus vaccine provide some protection against genital warts. Image: Karolinska Institutet

Just 2 doses of the human papillomavirus (HPV) vaccine reduced the risk of young women developing genital warts, although 3 doses provided even greater protection, according to a study published in JAMA today.

A 3-dose regimen of HPV vaccine is recommended for girls and young women in the United States and many other countries to reduce their risk of developing cervical cancer and other HPV-related conditions, such as genital warts. But the multiple-dose regimen, costs, and other concerns have dampened HPV vaccine’s uptake. According to the US Centers for Disease Control and Prevention, in 2012 only one-third of US teens received all 3 doses of the vaccine and a little more than half received at least 1 dose.

Some previous studies have suggested that fewer than 3 doses of the HPV vaccine may also reduce the effects of the virus to some extent. Now, Lisen Arnheim-Dahlström, PhD, of the Karolinska Institutet in Stockholm, Sweden, and her colleagues provide evidence that 1 or 2 doses may provide some protection against the development of genital warts, or condylomas.

The researchers followed a cohort of more than 1 million Swedish females between the ages of 10 and 24 years between 2006 and 2010. They identified 20 383 new cases of genital warts, including 322 that occurred among individuals who received at least 1 dose of the HPV vaccine. The most protection was offered by the 3-dose regimen, which was associated with incidence of 459 fewer cases of genital warts per 100 000 person-years. A 2-dose regimen was slightly less effective, reducing cases by 400 per 100 000 person-years. Receiving 1 dose of HPV vaccine reduced cases by 384 per 100 000 person-years.

Dr Arnheim-Dahlström spoke with news@JAMA about the results.

news@JAMA: Why did you decide to look at genital warts as an end point?

Dr Arnheim-Dahlström: Condyloma represents the earliest measurable disease outcome for the HPV vaccine, as the incubation time for condyloma is much shorter than for precancerous lesions of the cervix or cervical cancer.

news@JAMA: Do you think your findings strengthen the case that 2 doses might be enough to protect against HPV-related disease?

Dr Arnheim-Dahlström: The immunogenicity trials show that 2 doses mount high antibody responses against HPV types in the vaccine, and our study shows that receiving 2 doses was associated with substantial risk reduction. However, it is important to further evaluate this finding with cervical cancer as the end point.

news@JAMA: Are your results generalizable to the United States?

Dr Arnheim-Dahlström: Approximately 30% of the targeted population [adolescent girls aged 13-17 years] were vaccinated, which I think is comparable to the US vaccination rates. The result from our study is probably generalizable to the situation in the United States.

news@JAMA: Could HPV infections contracted before vaccination have affected your findings?

Dr Arnheim-Dahlström: It may be so that some study participants had an infection prior to vaccination. We do not know this because we could not measure HPV status in this study. However, we included into our statistical model buffer periods to account for [prior] infections.

news@JAMA: What questions remain to be answered?

Dr Arnheim-Dahlström: Will 3 doses still offer protection when measured with longer follow-up time? Will the results be different or the same when we study girls who received the vaccine when they are younger, 10 to 12 years? What about when higher vaccination coverage and herd immunity may be achieved? Further, what will the result be when we study outcomes such as precancerous lesions of the cervix.

news@JAMA: What would you say is the main take-home message?

Dr Arnheim-Dahlström: There are several important messages. This study is an important complement to the clinical trials, as they have data only on immunogenicity by dose level and not disease outcomes. Further, our population-based study may also be more generalizable to the more diverse populations actually getting vaccinated.

Still, the most important outcomes—precancerous lesions and cervical cancer—need to be studied as well. Clinicians and patients should stick to the recommended dose schedule until new recommendations are made.

Growing Concern Over Procedure for Hysterectomies and Fibroid Removal

Image: JAMA, ©AMA

Posted today on JAMA:

Two articles have been posted that examine a procedure for hysterectomies and fibroid removal known as electric uterine morcellation, which involves the use of an instrument for fragmenting fibroids or uterine tissue into smaller pieces for easier removal through a laparoscopic port. There is growing concern that this procedure has important risks, including:

  • Inadvertent dispersion and ectopic implantation of small tissue fragments during the procedure, causing symptoms and illness requiring intervention;
  • Dissemination of fragments of undetected and confined malignant tumors throughout the abdominal cavity, upstaging the cancer;
  • Injuries or death caused by damage from the blade of the instrument to organs.

A Viewpoint (available at this link) and JAMA Medical News & Perspectives article (available at this link) discuss the risks, potential alternatives, informed consent process and recommendations for addressing this issue.

Task Force Backs Screening Women for Gestational Diabetes Late in Pregnancy

A US task force recommends routinely screening women for gestational diabetes after 24 weeks of pregnancy. Image: MayaMoody/iStock.com

A US task force recommends routinely screening women for gestational diabetes after 24 weeks of pregnancy. Image: MayaMoody/iStock.com

All pregnant women should be screened for gestational diabetes but not until the pregnancy has passed the 24th week, according to a new recommendation from the US Preventive Services Task Force (USPSTF) published today in the Annals of Internal Medicine. In 2008, the task force had found insufficient evidence to support routine screening for gestational diabetes in women.

About 6% of pregnant women in the United States develop symptoms of diabetes during pregnancy. In certain populations, particularly minority populations, the rate can be as high as 25%. If left untreated, gestational diabetes increases the risk of poor outcomes for mother and child. Women with gestational diabetes may develop life-threatening preeclampsia, and the fetus may grow unusually large, leading to a complicated delivery and possible injury to the newborn. To avert these problems, nearly all (96%) US pregnant women are currently screened for this condition so that their blood sugar levels may be managed, if needed.

Women who are identified as having gestational diabetes may be advised to increase physical activity, make dietary changes, and monitor their glucose levels. If those steps don’t improve the condition, medications may be prescribed. The USPSTF in 2008 found inadequate evidence to support screening for gestational diabetes before or after 24 weeks, despite the widespread adoption of screening. Other prominent groups such as the American Academy of Family Physicians, the American Diabetes Association, and the Endocrine Society recommend screening after 24 weeks.

But the USPSTF’s new review of the evidence found enough evidence to support the benefits of screening for gestational diabetes after 24 weeks, and the task force has updated its recommendation accordingly. The review did not find sufficient evidence to support screening before 24 weeks, but the report notes that there may be specific circumstances in which a physician may choose to do so. For example, if a woman has risk factors that place her at greater risk, such as obesity or a family history of gestational diabetes, her physician may want to consider earlier screening.

Heart Health Education Efforts May Not Be Reaching Many Hispanic Women

Hispanic women are less likely than non-Hispanic white women to know that heart disease is the leading cause of death among women (Image: robeo/iStock.com).

Hispanic women are less likely than non-Hispanic white women to know that heart disease is the leading cause of death among women (Image: robeo/iStock.com).

Familiarity with heart disease risk factors is associated with improved lifestyle choices, heart health, and overall health. But Hispanic women living in the United States are less aware than their white counterparts of the risk heart disease poses to them and less accurate in estimating their weight—factors that may partially explain why hypertension, diabetes, and obesity affect minority women disproportionately.

The finding appears in the Journal of Women’s Health.

A study using face-to-face questionnaires completed by 382 Hispanic and 301 non-Hispanic white women participating in the Heart Health in Action database at Columbia University Medical Center in New York City found that Hispanic women were less likely than white women to correctly identify heart disease as the leading cause of death among women (27% vs 88%). Hispanic women were also less likely to know the symptoms of a heart attack or stroke compared with white women (58.5% vs 80.8%).

Women were excluded from the study if they were at high risk for heart disease, had a known history of coronary artery disease, had undergone a cardiovascular procedure, were pregnant, or had a history of heart attack or stroke.

Additionally, Hispanic women were less likely than white women (69.4% vs 82.9%) to correctly estimate their weight, and they were far more likely to underestimate it (24.8% vs 5.0%). Among the Hispanic women, those who spoke primarily Spanish or were bilingual were less likely than those who primarily spoke English to correctly identify that heart disease is the leading cause of death among women.

The researchers concluded that effective prevention strategies that target heart disease knowledge and awareness are needed for populations at risk for heart disease. “Persistently low CVD [cardiovascular disease] awareness poses continuing challenges for Hispanic women, health care professionals, and public health officials,” they wrote. “Education about CVD, weight perception, and healthy weight are critical steps in addressing the relationship between obesity and the rise in CVD mortality attributed to it.”