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Archive for March, 2012

Introducing Kathy Morelli, our new Guest Community Manager.

March 30th, 2012 by avatar

I have immensely enjoyed my time with Science and Sensibility! Thank you for the support and comments throughout the month of March. As my assignment draws to a close, I would like to introduce to you our newest Guest Community Manager, Kathy Morelli:

Kathy is a Licensed Professional Counselor in Wayne, NJ and the Director of BirthTouch, LLC®. She provides Marriage and Family Counseling in Wayne, New Jersey with a special interest in perinatal mood disorders, sexual abuse and its impact on parenting. EMDR is one of  the mindbody therapies she uses to address trauma. In addition, private childbirth education is available for those suffering from depression, anxiety or trauma. Kathy supports women & families in all birth & parenting choices, as she believes safe and loving parenting occurs on a contiuuum of good-enough, normal behaviors.

At her BirthTouch® website, she offers a private online support group for those suffering from perinatal mood disorders called BirthTouch® Social Connect. She blogs about the emotions of pregnancy, birth, postpartum and couples. Kathy is the author of BirthTouch® Shiatsu and Acupressure for the Childbearing Year and BirthTouch® Healing for Parents in the NICU.   Kathy has lectured on BirthTouch® at the University of Medicine and Dentistry of New Jersey’s Semmelweis Conference for Midwifery, several birth conferences, including BirthWorks®, HypnoBirthing®, at midwifery schools, and at Postpartum Support International’s Annual 2011 Conference. She presents trainings to allied health/birth organizations about maternal mental health, family systems and good-enough parenting and is found on web media, such as PBS’ This Emotional Life, writing and speaking about this subject. She is a CEU provider for DONA International. She  volunteers on Postpartum Support International’s warmline.

Kathy founded and co-moderates #MHON , a psycho-educational and supportive Twitter chat led by credentialed Mental Health professionals around mental health issues, hoping to reduce the stigma around mental illness.

Welcome aboard Kathy! Best wishes for the month of April.

Perinatal Mood Disorders, Postpartum Depression, PTSD, Uncategorized , , , ,

Is Elective Repeat Cesarean Surgery Truly Safer Than Planned VBAC?

March 28th, 2012 by avatar

The headline on a recent BBC News health article reads: “Planned repeat C-sections ‘safer.’ The article goes on to report on two studies that appear to support that conclusion, but do they really? Let’s see what the article says and follow with a look at the actual studies.

One of the studies, the BBC News article tells us, is a U.K. study of 159 cases of uterine rupture in which 139 occurred in women with a prior cesarean. The risk of scar rupture in women with a prior scar, it reports, was seven times greater in women having VBAC labors compared with women planning repeat cesareans, and the risk of the baby dying was three times higher.

That would seem to make a clear case for elective (no medical indication) repeat cesarean (ERC), but if we turn to the study itself, we find that the risk of scar rupture in a VBAC labor was 2 per 1000 VBAC labors versus 0.3 per 1000 planned repeat cesareans, or roughly 2 more scar ruptures per 1000 VBAC labors, not the large difference that “seven times greater” suggests. Moreover, the likelihood of scar rupture was influenced by modifiable factors. The use of prostaglandin, oxytocin, or both for initiating or augmenting labor increased the risk without improving the VBAC rate. In fact, misoprostol was the induction agent in 18% of induced women experiencing scar rupture, but none of the women not having scar rupture were given this agent. ACOG’s 2006 induction guidelines for VBAC labors prohibits using misoprostol because of its strong association with scar rupture. Furthermore, study authors theorize that one reason the scar rupture rate was so low in their study compared with some others was because double-layer uterine suturing, another modifiable practice, is the norm in the U.K..

As for VBAC labor tripling the rate of perinatal (intrapartum + neonatal) death compared with ERC, the study doesn’t give us this number (or maternal morbidity or mortality rates either, for that matter). The study actually only reports maternal and perinatal outcomes in the population overall, which included 20 women with rupture of an unscarred uterus, an event that may be more likely to produce severe adverse outcomes than a scar rupture. In addition, some of the neonatal deaths in women with prior cesarean may have been in women having emergent nonlabor cesareans. For example, three women had a scar rupture in conjunction with placenta previa. The extensive NIH systematic review  of VBAC reported that 6% of babies died as a result of scar rupture in a VBAC labor. We can use that number to calculate the odds of a baby dying in a VBAC labor in the U.K. study by multiplying it (0.06) by the U.K. study’s scar rupture rate (0.002). The result equals 0.00012 or 1 perinatal death per 10,000 VBAC labors. To be sure, every death is a tragedy, but we must also put this into perspective: that mortality is equivalent to the maternal mortality rate with ERC, which is 3 per 10,000, and much less than the fetal loss rate as a result of having an amniocentesis, which one modern-day study found to be 60 per 10,000.

The other study, according to the BBC News article, is an Australian study  of more than 2000 women planning their second delivery after a first cesarean. The BBC article states that the planned VBAC group had more stillbirths, and women were more likely to have severe bleeding, but gives no numbers.

Again, let’s turn to the actual study. The two planned VBAC deaths were unexplained fetal demises in infants born at 39 weeks, the implication being that ERC before that gestational age would have averted them. Perhaps they would have, but as the study  I analyzed in another blog post found, ERC at 39 weeks would have prevented only two of the six antepartum deaths.

The excess in severe hemorrhage (defined as > 1500 ml or transfusion) amounted to 1.5 more instances per 1000 VBAC labors, again, a small absolute difference, and a difference, moreover, that probably would have favored planned VBAC had not so few women had vaginal births. Maternal morbidity mostly occurs in labors that end in intrapartum cesareans, and the VBAC rate in this study was a dismal 43%. With physiologic care, the rate could have been as high as 81%. Even with typical management, studies have reported rates ranging from 61-72% in women with no prior vaginal births. In any case, however worrisome at the time, no differences were found in permanent sequelae such as hysterectomy.

And there is more: neither these studies nor the BBC news article considers the downstream consequences of accumulating cesarean scars, but they should. Even women who plan no more children may change their minds or continue with an unplanned pregnancy. According to the NIH systematic review, as the number of cesareans rises so does the risk of serious neonatal and maternal morbidity and perinatal mortality. By contrast, once a woman has a VBAC under her belt, so to speak, she is almost certain to go on having uneventful VBACs. Also, the review found that the risk of forming dense adhesions (internal scar tissue) rises with number of cesareans as well, thus increasing the likelihood of chronic pain and making any future abdominal surgery, not just future cesareans, more risky and difficult. Add these considerations into the mix, and the balance tips toward planning VBAC as the safer option for almost all women.

Headlines and articles like the one from the BBC News obstruct informed decision making by obscuring the true degree of comparative risk, and the studies contribute by failing to emphasize that better labor management in the previous delivery and current labor would improve outcomes. Planned VBAC is not without risks, but neither is ERC. Women deserve accurate, complete, and, most importantly, quantified information on which to decide on mode of birth after a cesarean. They also should have care in the primary cesarean that promotes safety in future VBACs and care in VBAC labors that promotes safe, healthy vaginal birth. To do less than that does women and their babies a serious disservice.

Cesarean Birth

Vitamin D: A look at the research behind the recommendations

March 26th, 2012 by avatar

Ah, spring is in the air. For me, spring brings to mind flowers, sunshine and vitamin D! In a recent article on healthychildren.org, the American Academy of Pediatrics discuss the recommendation that all breastfed infants be supplemented with 400IU of vitamin D per day. They extend this recommendation to non-breastfed babies consuming less than 32 ounces (1,000 mL) of vitamin D-fortified infant formula as well. Canada has been recommending 400IU of vitamin D per day for the breastfed baby since 1967.  The Canadian Paediatric Society (CPS)  also recommend  a daily dose of 400IU of vitamin D during April-October for formula-fed babies in northern communities. While the idea of providing breastfed infants with vitamin D supplements is not new, newer findings on vitamin D are important to recognize and share with the parents that we work with.

Vitamin D supplementation is about more than preventing rickets

Rickets, a disease that results in abnormal bone growth, can occur when the body is deficient of vitamin D, calcium and phosphorus (an in-depth review of vitamin D deficiency can be found here). Despite vitamin D fortification of certain food items and public awareness strategies, rickets is still a problem in North America, especially in northern latitudes. The Canadian Paediatric Surveillance Program reported 104 confirmed cases of rickets between 2002 and 2004 and there were 228 reported cases in the United States between 1986-2006.

Although the current prevalence of rickets is concerning, vitamin D supplementation is about more than preventing rickets. More recent evidence has suggested that vitamin D deficiency has also been linked to an increased lifetime risk of osteoporosis; asthma; autoimmune diseases such as rheumatoid arthritis, multiple sclerosis and inflammatory bowel diseases; diabetes; disturbed muscle function; resistance to tuberculosis; and the pathogenesis of specific types of cancer (reviewed by the CPS).  It has been estimated that in the United States alone, vitamin D deficiency carries an economic burden of $40 billion to $53 billion dollars per year, an amount that includes only the burden of disease from rickets and osteomalacia, associated deformities, bone fractures, muscle weakness, and pneumonia, as well as multiple sclerosis and common cancers associated epidemiologically with vitamin D deficiency such as prostate, colon, and breast cancers. It has also been estimated that somewhere between 50,000 to 70,000 people in the United States will die prematurely each year as a result of cancer related to insufficient vitamin D.  It is clear that vitamin D sufficency has both short term and lifelong benefits.

 

Supplements are the main source of Vitamin D for young infants

Assuming a mother is vitamin-D sufficient, and assuming a breastfed infant is consuming an average of 750mL of breastmilk per day, the amount of vitamin D the baby is receiving from the breastmilk is approximately 11-38 IU per day. This amount can be even less if mother is vitamin-D deficient due to factors such as clothing choice, skin color, diet, and geographical location. The amount of vitamin D currently recommended for breastfed infants is 400 IU per day. Clearly another source of vitamin D is needed for these infants. Although exposure to sunshine can increase vitamin D levels, direct sun exposure is not recommended for infants under 6 months of age. Therefore, the best option for infants that are exclusively breastfeed without adequate sun exposure is a vitamin D supplement of 400 IU per day.

Although vitamin D deficiency is not as commonly diagnosed in formula-fed infants due to the fortification of infant formula, it is still possible for these infants to suffer from vitamin D deficiency. In a 2006 prospective study from the UK, 50% of the children aged 0 to 5 presenting with rickets were formula-fed. It is therefore important to determine the daily intake of vitamin D in formula-fed infants based on the amount of formula consumed and the vitamin D content of the formula. It is for this reason that the AAP recommends all non-breastfed infants who are consuming less than 32 ounces (1 litre) per day of vitamin D-fortified formula receive a vitamin D supplement of 400 IU a day. In addition, the CPS advises families in northern communities to supplement formula-fed infants with 400IU of vitamin D per day during the months of October to April, even if they are drinking 32 ounces (1 litre) of formula daily.

 

More Information for Parents

There are many great information sources for consumers. Here are a few sources of online information that you may wish to share with the parents you work with:

Vitamin D Quick Facts from the National Institutes of Health

Vitamin D and your Baby 

Vitamin D summary for parents from the CPS

A parent-friendly video from the Vancouver Island Health Authority in British Columbia, Canada.

Babies

New Guidelines for Pregnancy and Chickenpox

March 22nd, 2012 by avatar

In this month’s edition of the Journal of Obstetrics and Gynaecology Canada, the SOGC released a new clinical practice guideline for the management of varicella infection in pregnancy.  Varicella zoster virus (VZV) infection, commonly referred to as chickenpox, is a common childhood disease that can affect the developing fetus if the mother contracts the disease during pregnancy. Here are some of the key points from the guideline that you should be aware of:

 

Chickenpox in pregnancy: the numbers

  • 90% or more of pregnant women are immune to the varicella virus because of childhood exposure or varicella immunization.

 

  • Varicella infection affects 2-3 pregnancies out of 1000 every year. This equates to 700-1050 cases in Canada per year and 8,100-12,100 cases in the US per year.

 

  • Of those pregnant women with an active varicella infection, 5-10% will develop a serious respiratory disease known as pneumonitis.  This means approximately 35-105 women in Canada and 405-1210 women in the US will develop pneumonitis each year. Women who develop pneumonitis may need intubation and mechanical ventilation and are at a much higher risk of death.

 

  • VZV can cross the placenta and lead to congenital varicella syndrome (CVS), a condition that results in malformations and deformations such as partial limb reductions. Fetal infection is rare, with a rate of 0.4% prior to 13 weeks gestation and a rate of 2% between 13-20 weeks gestation. There are about 4 cases per year in Canada and 41 cases per year in the US.

 

  • If the mother contracts chickenpox between 5 days before birth and 2 days after birth, the newborn can develop neonatal varicella.  Varicella in a newborn can develop into disseminated visceral and central nervous system disease, which is often fatal. Approximately 20-30% of babies born to affected mothers at the time of delivery will develop neonatal varicella and it will be fatal in up to 30% of those infants.

 

Key Recommendations for Women

  • If a woman does not recall having chickenpox as a child, then she should receive the varicella immunization prior to conception or after the birth of her child. The SOGC and AAP  recommend waiting at least one month after receiving the immunization before becoming pregnant. However, a pregnancy registry established by the vaccine’s manufacturer shows no cases of CVS in the 362 recorded cases of women who conceived within 3 months of receiving the varicella vaccine.

 

  • If a pregnant woman is not immune to VZV, she should seek immediate medical help if she comes in contact with a contagious person. Treatment with varicella zoster immunoglobin (VZIG) will be given to reduce the risk of complications of maternal infection.

 

  • A pregnant woman who contracts chickenpox should be treated with an antiviral drug.

 

  • If a mother contracted chickenpox within 5 days before and 2 days after delivery, then her child should be treated with VZIG to reduce the risk of neonatal varicella.

 

Recommendations in the SOGC’s clinical practice guideline are comparable to recommendations from the Center for Disease Control.

A parent-friendly fact sheet on the topic of varicella vaccination has been created by the Organization of Teratology Information Specialists (OTIS).

Information on other immunizations during pregnancy can be obtained through the Center for Disease Control.

And now for today’s question to you, the reader: How will you use this information?

Evidence Based Medicine, Practice Guidelines

Prior Cesarean Surgery Increases Future Likelihood of Stillbirth

March 20th, 2012 by avatar

Last month yet another study appeared reporting that compared with first vaginal birth, first cesarean increased the likelihood of late antepartum fetal death in the next pregnancy. The study encompassed 10,712 women with one prior birth who had pregnancy duration of 34 weeks or more and were carrying a single, normally-formed fetus. With first delivery via cesarean (22%), the fetal death rate at or beyond 34 weeks’ gestation in the next pregnancy was 2.5 per 1000 compared with 0.5 per 1000 with first birth vaginally, or 2 more late antepartum fetal deaths per 1000 with first delivery via cesarean surgery.

I say “yet another study” because it joins eight others. Six of the eight, one each in Scotland, England , Germany, and Canada and two in Australia, one in South Australia and the other in New South Wales, also reported more late fetal deaths with first cesarean delivery. In two of them, the difference failed to achieve statistical significance, meaning the difference may have been due to chance, but the number of women having a first cesarean was too small to reliably detect a difference. A third study among the six did not perform a significance calculation. The seventh study, conducted in Missouri,  reported an excess among black women but not white women. Mortality rates varied substantially from study to study, but excesses with prior cesarean were similar, ranging from 0.3 to 1.6 per 1000 (mean 1.1 per 1000). The eighth study, a U.S. national study , reported no difference (0.7 per 1000 first cesarean delivery vs. 0.8 per 1000 first birth vaginal) in women with one prior birth, no underlying medical conditions, and a fetus with no structural or chromosomal abnormalities. The gap actually may be wider than appears. Some of the studies restricted analysis to unexplained deaths, which excluded deaths secondary to placenta previa, and accreta and placental abruption, all of which are associated with prior cesarean.

The consistency of this finding is compelling, but you may be thinking that it shouldn’t be surprising because some of the reasons that may lead to cesarean in the first pregnancy would increase the risk of fetal demise in the next pregnancy. Ah, but unlike the other studies, which used population databases, this one was conducted at a single hospital, which means investigators could explore the effect of confounding factors. They found that the association remained statistically significant after controlling for maternal age, height, weight, hypertension, and diabetes, and it strengthened when they confined analysis to women known to have first births to a full-term live infant (n = 4425): 6 per 1000 with first delivery by cesarean versus 1 per 1000 with first birth vaginal, or 5 more late antepartum deaths per 1000 in women with first cesarean delivery in this subgroup. The cause of the excess is unknown, but it would appear that a scarred uterus becomes a less hospitable environment for pregnancy.

Certainly, this risk should not deter performing a cesarean when the health of mother or baby is at stake or everything has been tried, but it seems unlikely that the baby can be born vaginally. However, with one in three first time mothers delivering via cesarean surgery, for many cesareans, clearly, this is not the case. Many cesareans could be prevented with better labor management and by having more patience. As the ninth study concludes, “Our findings reinforce the importance of considering the impact cesarean birth may have on future pregnancies when making decisions regarding method of birth” (p. 16). Amen to that.

Authoritative Knowledge, Cesarean Birth, Guest Posts ,