Danish Siddiqui

Randomized Clinical Trials behind Level A Recommendations in Obstetric Practice Bulletins: Compliance with CONSORT Statement

We appraised the compliance of randomized clinical trials (RCTs) cited for level A recommendations in obstetric practice bulletins (OPBs) and published after the CONSORT (Consolidated Standards of Reporting Trials, published 1996) statement. From the CONSORT checklist, we identified 50 separate items the RCTs should describe in the article and assigned 1 point if present; 0, if absent. The CONSORT score was the total points, expressed as a percentage. From 1998 to 2006, American College of Obstetricians and Gynecologists published 68 level A obstetric recommendations, and 20 (29%) are supported by > or = 1 RCT published after 1997. The median CONSORT score for the 32 RCTs published after the statement was 73% (range 30 to 100%). Only four RCTs complied with 90% of the CONSORT statement. RCTs supporting level A recommendations in OPB have variable compliance with CONSORT. Recommendations that lack quality RCTs should prompt further studies into the topic.

Racial and ethnic disparities in infant mortality in the United States: The role of gestational age

OBJECTIVEnWe assessed the association among gestational age (GA) at birth, timing of death, and risk status of the pregnancy and racial/ethnic disparities in infant mortality rate in the United States.nnnSTUDY DESIGNnWe utilized U.S. 2000 to 2004 birth cohort-linked birth and infant death data restricted to nonanomalous singleton live births. Multivariable log-binomial regression models were fit to evaluate racial/ethnic disparities in infant mortality while adjusting for potential confounders.nnnRESULTSnCompared with whites, blacks had a higher adjusted infant mortality rate (IMR) (risk ratio [RR] 1.96, 95% confidence interval [CI] 1.91, 2.01), and Hispanics had a lower adjusted IMR (RR 0.79, 95% CI 0.76, 0.82). When categorized by GA, at 24 to 31 weeks, the adjusted early neonatal mortality (ENM) is significantly lower for black than whites, similar at 32 to 36 weeks, and at 37 weeks or more, blacks have significantly higher ENM.nnnCONCLUSIONSnThe racial/ethnic disparities in infant mortality in the United States persist and vary across GA. These disparities may largely be driven by the excess post-neonatal deaths among blacks.

Skin Closure of Pfannenstiel Incision with Dermabond, Staples, or Suture during Cesarean Delivery: Experience of a Single Attending

OBJECTIVEnWe aimed to compare the rates of wound separation (WS) and surgical site infection (SSI) after cesarean delivery (CD) by a single surgeon. Pfannenstiel skin incision (PSI) was closed with Dermabond, staples, or suture.nnnSTUDY DESIGNnRetrospectively all women having CD via PSI were identified. WS and SSI rates with Dermabond were compared with other two techniques.nnnRESULTSnOf 239 CDs performed, 88% (n = 211) were available for postpartum evaluation. The PSI was closed with Dermabond in 85 (40%), staples in 76 (36%), and suture in 50 (24%). Overall WS rate was 7%; with Dermabond, it was 5% versus 13% with staple (p = 0.090) and 2% with suture (p = 0.651). Post hoc calculation suggests a randomization of 4325 women is needed to determine if Dermabond has one-third less wound complication than suture.nnnCONCLUSIONnFor the PSI closure, Dermabond may be a useful alternative skin closure device, though a randomized trial is warranted.

Comparison of two national guidelines in obstetrics: American versus royal college of obstetricians and gynecologists.

We compared the obstetric guidelines published by the American College of Obstetrics And Gynecology (ACOG) and Royal Colleges of Obstetricians and Gynaecologists (RCOG). The references and the recommendations in the current practice bulletins (PBs) and green guidelines (GGs) were compared. As of December 2007, there were 42 PBs and 27 GGs. There were nine common obstetric topics between ACOG and RCOG. Each GG had almost twice as many recommendations as the corresponding PB (median 7 versus 15; Pu2009<u20090.0001); 28% of ACOGs recommendations were confirmed by RCOG and 16% disagreed. Recommendations of the common obstetric guidelines by ACOG and RCOG were not comparable the majority of the time.

Association of Fetal Abdominal-Head Circumference Size Difference With Shoulder Dystocia: A Multicenter Study

Objectiveu2003This study aims to determine if shoulder dystocia is associated with a difference in the fetal abdominal (AC) to head circumference (HC) of 50u2009mm or more noted on antenatal ultrasound. Study Designu2003A multicenter matched case–control study was performed comparing women who had shoulder dystocia to controls who did not. Women with vaginal births of live born nonanomalous singletonsu2009≥u200936 weeks of gestation with an antenatal ultrasound within 4 weeks of delivery were included. Controls were matched for gestational age, route of delivery, and diabetes status. Resultsu2003We identified 181 matched pairs. Only 5% of the fetuses had an AC to HC ofu2009≥u200950 mm. The proportion of AC to HC difference ofu2009≥u200950u2009mm was significantly higher in shoulder dystocia cases (8%) than controls (1%, pu2009=u20090.002). With multivariate regression, the three significant factors associated with shoulder dystocia were AC to HCu2009≥u200950u2009mm (odds ratio [OR], 7.3; confidence interval [CI], 1.6–33.3; pu2009=u20090.010), femur length (OR, 1.1; CI, 1.0–1.2; pu2009=u20090.002), and induced labor (OR, 1.8; CI, 1.1–3.1; pu2009=u20090.027). Conclusionu2003A prenatal ultrasound finding of a difference in AC to HC ofu2009≥u200950u2009mm while uncommon is associated with shoulder dystocia.

Knowledge gap of recommendations in ACOG practice bulletins: a survey of members of the Central Association of Obstetricians and Gynecologists.

Abstract The purpose of this survey was to assess the knowledge gap of recommendations in practice bulletins (PBs). A survey consisting of three questions for 12 selected PBs (six obstetric and six gynecologic) was developed and sent to members of the Central Association. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Of the 385 active members, 100 (26%) returned the survey. The overall correct score was 49%. Respondents were significantly more likely to know recommendations in obstetric PBs (60%) than gynecologic PBs (39%; OR 2.45, 95% CI 2.12–2.81). Maternal-fetal medicine sub-specialists (n=27), compared with obstetricians-gynecologists (n=66), did significantly better with obstetric PBs (67% vs. 59%; OR 1.42, 95% CI 1.32–1.77) and substantially worse with gynecologic topics (34% vs. 39%; OR 0.79, 95% CI 0.63–0.98). In conclusion, since members of the Central Association have a substantial knowledge gap, there are ample opportunities to educate and reinforce PB recommendations.

Abdominal hysterectomy for benign indications: evidence-based guidance for surgical decisions

The purpose of this review is to provide evidence-based guidance for surgical decisions during abdominal hysterectomy performed for benign indications. Using combinations of terms “abdominal,” “hysterectomy,” and “randomized clinical trials (RCT),” we performed Ovid, PubMed, and Cochrane searches for publications between 1988 and 2008. After reviewing over 3,000 abstracts, 19 RCT were identified. There are no grade A recommendations. The only grade B suggestion is use of a bipolar vessel sealing device (LigaSure) for vascular pedicles rather than sutures. Routine closure of peritoneum should be avoided. Evidence behind 71xa0% (15/21) of surgical steps is insufficient (grade I). Despite its common performance, there are no grade A recommendations that can be made for the technical aspects of abdominal hysterectomy. Since almost 70xa0% of the surgical steps during abdominal hysterectomy lack randomized clinical trials, adequately designed studies are needed to decrease perioperative morbidity.

American College of Obstetricians and Gynecologists Practice Bulletins: Original versus Revised

We compared the types (A, B, or C) of recommendations and levels (I, II, III, or others) of references in the original versus revised practice bulletins (PBs). American College of Obstetricians and Gynecologists (ACOG) compendiums and Web site were used to obtain the PBs. Chi-square test for trend or Wilcoxon matched-pairs tests were used. From December 1998 to December 2008, ACOG published 78 PBs, of which 24% (19) have been revised. Neither the median numbers of recommendations per PB (8 to 10; P = 0.235) nor the type ( P = 0.155) increased significantly. Additionally, the level of references ( P = 0.130) and the type of journals they were published in did not vary significantly ( P = 0.554). In 10 years, approximately one in four PBs has been revised and the number of recommendations per PB has increased, but the types of suggestions and level of references has not improved appreciably.