Catherine S. Stika

Single-dose methotrexate for the treatment of ectopic pregnancy: Northwestern Memorial Hospital three-year experience

OBJECTIVE Our purpose was to evaluate the effectiveness of single-dose intramuscular methotrexate in the treatment of ectopic pregnancies by physicians in the Department of Obstetrics and Gynecology of Northwestern Memorial Hospital and to compare the results with those of previously published studies. STUDY DESIGN A retrospective chart review was performed of 50 patients with ectopic pregnancies treated with single-dose methotrexate according to the protocol of Stovall et al. from January 1992 to February 1995. RESULTS The mean pretreatment level of beta-human chorionic gonadotropin was 1896.4 +/- 2399 mlU/ml. Only 32 women (64%) were successfully treated with a single dose of methotrexate. An additional 7 women required a second or third injection. The combined success rate for medical management of ectopic pregnancy with one to three doses of methotrexate was 78% (39 women). Pretreatment beta-human chorionic gonadotropin levels were significantly lower in women who responded to single-dose therapy than in those who required either two or three doses or who had failure of medical management (p = 0.0011). The mean time to resolution of beta-human chorionic gonadotropin was 26.5 +/- 17 days. Higher pretreatment levels correlated with longer resolution time (r = 0.83, p < 0.001). Eleven women (22%) with failure of medical management required surgery. CONCLUSIONS In our series single-dose methotrexate was only 64% successful. Women with a pretreatment beta-human chorionic gonadotropin level >5000 mlU/ml had a greater probability of requiring either surgical intervention or multiple doses of methotrexate. The potential for emergency surgery remains an important risk.

Placenta previa: A 22-year analysis

OBJECTIVE Our purpose was to identify what anesthetic method is safer for women with a placenta previa. STUDY DESIGN We retrospectively reviewed all women with placenta previa who underwent cesarean delivery during the period January 1, 1976-December 31, 1997 at Northwestern Memorial Hospital. RESULTS Of 93,384 deliveries, placenta previa was found in 514 women. Identifiable trends with time included an increasing incidence of placenta previa (r = 0.54, P <.01); cesarean hysterectomy (r = 0.54, P <.01); placenta accreta (r = 0.45, P <.03); and regional anesthesia (r = 0.84, P <.0001). The mean gestational age at delivery was 35.3 +/- 3.4 weeks and did not change with time. General anesthesia was used for delivery in 380 women and regional anesthesia was used for 134 women. Prior cesarean delivery and general anesthesia were independent predictors of the need for blood transfusion, but only prior cesarean delivery was a predictor of the need for hysterectomy. General anesthesia increased the estimated blood loss, was associated with a lower postoperative hemoglobin concentration, and increased the need for blood transfusion. Elective and emergent deliveries did not differ in estimated blood loss, in postoperative hemoglobin concentrations, or in the incidence of intraoperative and anesthesia complications. Regional and general anesthesia did not differ in the incidence of intraoperative and anesthesia complications. CONCLUSIONS In women with placenta previa, general anesthesia increased intraoperative blood loss and the need for blood transfusion. Regional anesthesia appears to be a safe alternative.

Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block

BACKGROUND This study was conducted to investigate the effects of a 1% lidocaine paracervical block on perceived patient pain during intrauterine device (IUD) insertion. STUDY DESIGN We randomized 50 women undergoing IUD insertion to receive either a 10-mL 1% lidocaine paracervical block or no local anesthetic before IUD insertion. Women marked their pain on a 100-mm visual analogue scale (VAS) (0 mm = no pain, 100 mm = worst pain possible) at various points of the procedure (speculum insertion, tenaculum placement, paracervical block administration, IUD insertion and 5 min postprocedure). RESULTS Twenty-six women received the paracervical block before IUD insertion, and 24 received no local anesthesia. Groups were similar in age, parity, ethnicity, education and complications. Women who received the paracervical block reported a median VAS score of 24.0 mm with IUD insertion, and women who did not receive local anesthetic reported a median VAS score of 62.0 mm with IUD insertion; p=.09. CONCLUSION Compared with no anesthetic, a 1% lidocaine paracervical block did not result in a statistically significant decrease in perceived pain with IUD insertion.

Clinical Spectrum of Vulva Metastatic Crohn’s Disease

Crohn’s disease is a chronic granulomatous disorder that may involve any segment of the gastrointestinal tract. Extraintestinal manifestations of Crohn’s disease such as erythema nodosum and pyoderma gangrenosum are well recognized and appreciated. However, metastatic Crohn’s disease (MCD), defined as the same granulomatous inflammation seen in Crohn’s disease but at a skin site distant to the gastrointestinal tract, is less well recognized. We report three cases of MCD involving the perianal and vulvar skin that initially presented with vulvar pain.

Ultrasound evaluation of the endometrium after medical termination of pregnancy

OBJECTIVE: To determine ultrasound parameters associated with the need for clinical intervention after mifepristone and misoprostol termination of pregnancy. METHODS: Charts of patients undergoing medical termination according to a standard protocol in a 13-month period were reviewed. Endometrial thickness and the presence of gestational sac, fluid interface, or complex echoes on postprocedure ultrasonogram were recorded. Repeat doses of medication, surgical intervention, and complications were noted. Success was defined as an abortion completed after a single course of medical therapy. RESULTS: Postprocedure ultrasonograms were available for 525 of 684 patients. Endometrial thickness was measurable in 437 cases. The observed mean endometrial thickness was 4.10 ± 1.80 mm (range 0.67–13.4 mm). Endometrial thickness was inversely proportional to the number of days after initiation of therapy when ultrasonography was performed (r = –0.22; P < .001). The endometrium was thicker in the women who had failed than in those who had a successful medical abortion (6.15 ± 1.95 mm [range 3.35–10.0 mm] versus 4.01 ± 1.75 mm [range 0.67–13.4 mm], respectively; P < .001), but the wide overlap in endometrial thicknesses nullified the clinical usefulness of this difference. CONCLUSION: Endometrial thickness after administration of a single dose of mifepristone and misoprostol for medical termination should not dictate clinical intervention. The decision to treat should be based on the presence of a persistent gestational sac or compelling clinical signs and symptoms. LEVEL OF EVIDENCE: II-3

Providing Contraception for Women Taking Potentially Teratogenic Medications: A Survey of Internal Medicine Physicians’ Knowledge, Attitudes and Barriers

ABSTRACTBACKGROUNDThe majority of women prescribed category D or X medications may not receive adequate contraceptive counseling or a reliable contraceptive method. Physicians who prescribe potentially teratogenic medications have a responsibility to provide women with contraceptive counseling, a method of highly-effective contraception, or both.OBJECTIVEInvestigate the knowledge, beliefs and barriers of primary care physicians toward providing adequate contraception to women taking potential teratogens.DESIGN & PARTICIPANTSSelf-administered confidential survey of primary care internal medicine physicians at an urban, academic medical center.MEASUREMENTSKnowledge of potential teratogenic medications and contraceptive failure rates was assessed. Participants’ beliefs about adequacy of their medical education, practice limitations and attitudes toward improving provision of contraception to women on potential teratogens were assessed.RESULTSOne hundred and ten physicians responded (57.3%). Nearly two-thirds (62.3%) of participants had cared for reproductive aged women taking category D or X medications in the past year. The mean percent of correctly identified category D or X medications was 58.4% (SD 22.1%). The mean percent correct for knowledge of published contraceptive failure rates was 64.6% (SD 23.1%). Most respondents (87.6%) felt it is the responsibility of primary care physicians to provide contraception. Time constraints were reported to be somewhat or very limiting by 61.3% and over half felt medical school (63.2%) or residency (58.1%) inadequately prepared them to prescribe or counsel about contraceptives.CONCLUSIONSPrimary care physicians commonly encounter reproductive age women taking category D or X medications, but may lack sufficient knowledge and time to counsel about potential teratogens and contraception to prevent fetal exposure to these drugs.

Methotrexate: the pharmacology behind medical treatment for ectopic pregnancy.

Previously established as a chemotherapeutic agent for decades, methotrexate has been adapted for use as a medical therapy for unruptured ectopic pregnancies. Its mechanism of action, competitive inhibition of folate-dependent steps in nucleic acid synthesis, effectively kills the rapidly dividing ectopic trophoblast. However, the same action on normal cells is the basis for many of its adverse effects.

Epistaxis of pregnancy and association with postpartum hemorrhage.

OBJECTIVE: To estimate the prevalence of epistaxis among pregnant women and to investigate if epistaxis of pregnancy is associated with an increased risk of postpartum hemorrhage. METHODS: A cohort of 1,475 pregnant women presenting to labor and delivery at term were asked to complete a survey about epistaxis and other traditional risk factors for bleeding. Results were compared with those from a cohort of 275 nonpregnant women presenting for routine gynecologic care to estimate the effect of pregnancy on the prevalence of epistaxis. The association between epistaxis of pregnancy and risk of bleeding was estimated by comparing rates of postpartum hemorrhage between pregnant women with and without epistaxis. RESULTS: Final data analysis was performed on 1,470 pregnant women and 275 nonpregnant women. The prevalence of epistaxis was significantly increased in pregnant women compared with nonpregnant women (20.3% compared with 6.2%; P<.001). Women with epistaxis of pregnancy were at increased risk of postpartum hemorrhage compared with women without epistaxis (10.7% compared with 6.7%; P=.02). The increased risk of hemorrhage remained after controlling for cesarean delivery and after exclusion of women who reported epistaxis before pregnancy. Other traditional risk factors for bleeding such as gingival bleeding, O blood type, and easy bruising were not associated with increased risk of postpartum hemorrhage. CONCLUSION: Epistaxis is a common problem during pregnancy that may be associated with an increased risk of postpartum hemorrhage. As in the nonpregnant population, eliciting a history of epistaxis may help to identify women at risk of disordered hemostasis. LEVEL OF EVIDENCE: II

Double Duty: Does Epidural Labor Analgesia Reduce Both Pain and Postpartum Depression?

Nearly one-third of pregnant women in the United States undergo cesarean delivery.1 Effective analgesia is crucial to maximize the mother’s comfort, increase her mobility, and support lactation and emotional attachment to her newborn. The incidence of severe acute postpartum pain is approximately 11%.2 Chronic pain incidence varies by study and ranges from 1% to 4% to 10% after vaginal delivery and 6% to 18% after cesarean delivery.3,4 Chronic pain frequently co-occurs with depression. Eisenach et al.2 evaluated whether mode of delivery or acute postpartum pain was associated with persistent pain and depression 8 weeks after childbirth in a multicenter, prospective, longitudinal cohort study (n = 1288). The prevalence of severe acute pain within 36 hours of birth was 10.9%. Women with severe acute pain had a 2.5-fold increased risk of persistent pain and a 3-fold increased risk for postpartum depression compared with those with mild postpartum pain.

Transdermal Estradiol Treatment for Postpartum Depression: A Pilot Randomized Trial

Abstract Postpartum depression occurs in 14.5% of women in the first 3 months after birth. This study was an 8-week acute phase randomized trial with 3 cells (transdermal estradiol [E2], sertraline [SERT], and placebo [PL]) for the treatment of postpartum major depressive disorder. However, the study was stopped after batch analysis revealed that the E2 serum concentrations were lower than prestudy projections. This paper explores our experiences that will inform future investigations of therapeutic E2 use. Explanations for the low E2 concentrations were as follows: (1) study patch nonadhesion, which did not explain the low concentrations across the entire sample. (2) Ineffective transdermal patch preparations, although 2 different patch preparations were used and no significant main effect of patch type on E2 concentrations was found. (3) Obesity, at study entry, E2-treated women had body mass index of 32.9 (7.4) (mean [SD]). No pharmacokinetic data comparing E2 concentrations from transdermal patches in obese women versus normal weight controls are available. (4) Induction of cytochrome P450 (CYP450) 3A4 and other E2 elimination pathways in pregnancy. CYP4503A4 is induced in pregnancy and is a pathway for the metabolism of E2. Conversion to estrone and phase II metabolism via glucuronidation and sulfation, which also increase in pregnancy, are routes of E2 elimination. The time required for these pathways to normalize after delivery has not been elucidated. The observation that transdermal E2 doses greater than 100 &mgr;g/d did not increase serum concentrations was unexpected. Another hypothesis consistent with this observation is suppression of endogenous E2 secretion with increasing exogenous E2 dosing.