Malavika Prabhu

Pelvic Inflammatory Disease: Current concepts in pathogenesis, diagnosis and treatment

Pelvic inflammatory disease (PID) is characterized by infection and inflammation of the upper genital tract in women and can cause significant reproductive health sequelae for women. Although a definitive diagnosis of PID is made by laparoscopic visualization of inflamed, purulent fallopian tubes, PID is generally a clinical diagnosis and thus represents a diagnostic challenge. Therefore, diagnosis and treatment algorithms advise a high index of suspicion for PID in any woman of reproductive age with pelvic or abdominal pain. Antibiotic therapy should be started early, and given for an adequate period of time to reduce the risk of complications. Coverage for anaerobic organisms should be considered in most cases.

A Shared Decision-making Intervention to Guide Opioid Prescribing After Cesarean Delivery

OBJECTIVE To assess whether a shared decision-making intervention decreases the quantity of oxycodone tablets prescribed after cesarean delivery. TECHNIQUE A tablet computer-based decision aid formed the basis of a shared decision-making session to guide opioid prescribing after cesarean delivery. Women first received information on typical trajectories of pain resolution and expected opioid use after cesarean delivery and then chose the number of tablets of 5 mg oxycodone they would be prescribed up to the institutional standard prescription of 40 tablets. EXPERIENCE From April 11, 2016, to June 10, 2016, 105 women were screened, 75 were eligible, and 51 consented to participate; one patient was excluded after enrollment as a result of prolonged hospitalization. The median number of tablets (5 mg oxycodone) women chose for their prescription was 20.0 (interquartile range 15.0-25.0), which was less than the standard 40-tablet prescription (P<.001). CONCLUSION A shared decision-making approach to opioid prescribing after cesarean delivery was associated with approximately a 50% decrease in the number of opioids prescribed postoperatively in this cohort compared with our institutional standard prescription. This approach is a promising strategy to reduce the amount of leftover opioid medication after treatment of acute postcesarean pain. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02770612.

Risk of Cesarean Delivery among Nulliparous Asian-Indian Women with Term Singleton Pregnancies

Objective Asian‐Indian women are a growing population in the United States, but little data exist about their risk of cesarean delivery (CD). We characterize the odds of CD among Asian‐Indian women and determine whether neonatal birth weight modifies this relationship. Study Design This is a retrospective cohort study using an administrative perinatal database from California. We identified 1,029,940 nulliparous women with live, singleton, nonanomalous deliveries between 37 and 42 completed weeks of gestation. We performed multivariable logistic regression analyses to determine if Asian‐Indian women were more likely to deliver by CD, compared with white non‐Hispanic women, adjusting for sociodemographic and clinical variables. We explored if birth weight was an effect modifier, testing the interaction terms significance using Walds test, and performed multivariable logistic regressions stratified by birth weight category. Results Asian‐Indian women comprised 2.0% of the cohort. Compared with white non‐Hispanic women, Asian‐Indian women had an adjusted odds of 1.41 (95% confidence interval: 1.36‐1.46) for CD. However, we noted effect modification of birth weight on the odds of CD by race/ethnicity (p < 0.001). Among all birth weight categories exceeding 3,000 g, Asian‐Indian women had higher odds of CD than white non‐Hispanic women. Conclusion Asian‐Indian women are at greater risk of CD than white non‐Hispanic women when birthweight exceeds 3,000 g.

Antenatal bleeding: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data

http://dx.doi.org/10.1016/j.vaccine.2017.01.081 0264-410X/ 2017 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ⇑ Corresponding author. E-mail address: mprabhu@partners.org (M. Prabhu). 1 Brighton Collaboration homepage: http://www.brightoncollaboration.org. 2 Present address: University of Washington, Seattle, USA. Malavika Prabhu a,⇑, Linda O. Eckert , Michael Belfort , Isaac Babarinsa , Cande V. Ananth , Robert M. Silver , Elizabeth Stringer , Lee Meller , Jay King , Richard Hayman , Sonali Kochhar, Laura Riley , for The Brighton Collaboration Antenatal Bleeding Working Group 1

Postpartum anemia: missed opportunities for prevention and recognition.

I n their article, “Patterns and Predictors of Severe Postpartum Anemia after Cesarean Section,” Butwick and colleagues find that postpartum anemia is common, affecting 7.3% of the post-Cesarean delivery population. As Cesarean delivery is the most frequently performed surgical procedure in the United States, with 1.3 million Cesarean deliveries in 2014, postpartum anemia after Cesarean delivery affects approximately 100,000 women annually. Postpartum anemia is an important clinical entity, as several studies have demonstrated a link between postpartum anemia and postpartum depression and fatigue, as well as other cognitive sequelae. Moreover, it is associated with adverse future pregnancy outcomes if subsequent pregnancies occur after a short interpregnancy interval. In the analysis by Butwick and colleagues, predelivery anemia was the most important predictor of postpartum anemia, accounting for 31% of cases. This observation suggests that a large proportion of cases of postpartum anemia may be preventable through better screening and treatment of predelivery anemia. Anemia in the antepartum period occurs in part due to hemodilution, as the increase in plasma expansion outpaces the increase in red blood cell (RBC) mass and in part due to iron deficiency (or, less commonly, other etiologies). The nadir in hemoglobin (Hb) is most pronounced in the late second or early third trimester (weeks 28-34 of pregnancy) and selfcorrects toward term, when plasma expansion is complete but RBC mass continues to expand. The American College of Obstetrics and Gynecology (ACOG) and the Centers for Disease Control and Prevention (CDC) currently recommend screening for anemia with a complete blood count (CBC) in the beginning of pregnancy and in the late second or early third trimester. These organizations define anemia as a Hb level of less than 11g/dL in the first and third trimester and less than 10.5 g/dL in the second trimester. Once identified, how should predelivery anemia be treated optimally? Workup and management are individualized, although the most common etiology is iron deficiency. Available data suggest a prevalence of iron-deficiency anemia in the third trimester ranging from 2% to 5% in the general US population and up to 27% in certain high-risk groups. The prevalence of iron-deficiency anemia in the developing world is most likely much higher. Iron supplementation and dietary counseling are therefore generally the first line of therapy. After the initial test and treatment with these measures, in the absence of profound anemia or clinical symptoms, a CBC is not commonly repeated prior to the delivery admission. The data presented by Butwick and colleagues suggest a relatively high prevalence of predelivery anemia (12.5%, among those with a documented predelivery Hb) in the setting of routine practice. This observation argues that there is a need for additional prevention and that an additional CBC, perhaps at 34 to 36 weeks, may be indicated to allow time for additional predelivery intervention. Such intervention might include intravenous (IV) iron supplementation and, rarely, a blood transfusion. Postpartum hemorrhage (PPH) was the second most important source of postpartum anemia, accounting for 14% of cases. PPH is defined as blood loss of more than 1000 mL at Cesarean delivery and affects 1.5% to 3.5% of all Cesarean deliveries. PPH is one of the most common sources of pregnancy-related morbidity and mortality and one of the most preventable etiologies of these outcomes. Developing systems-based approaches to optimize the prevention and, when it occurs, treatment of PPH has been an important priority in obstetrics. In addition to decreasing the risks for severe morbidity and mortality, these efforts may have value in decreasing the occurrence of postpartum anemia. The National Partnership on Maternal Safety recently created a Consensus Bundle for the Management of Obstetric Hemorrhage, with pragmatic tasks highlighting four key aspects: 1) readiness, 2) recognition and prevention, 3) response, and 4) reporting and systems learning. Bundles, such as this, can improve outcomes by reducing variation in care, promoting awareness and communication within a multidisciplinary team, and promoting the use of improvement methods to redesign care processes. The goal of the National Partnership is for the Obstetric Hemorrhage bundle to be adopted in every delivery center in the United States, BTB is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the NIH (Bethesda, MD) under Award K08HD075831. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. doi:10.1111/trf.13927

Perioperative pain management strategies among women having reproductive surgeries

This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.

Development of World Health Organization (WHO) recommendations for appropriate clinical trial endpoints for next-generation Human Papillomavirus (HPV) vaccines

The World Health Organization (WHO) serves as a key organization to bring together experts along the continuum of vaccine development and regulatory approval, among its other functions. Using the revision of WHOs guidelines on prophylactic human papillomavirus (HPV) vaccine as an example, we describe the process by which (1) a need to revise the guidelines was identified; (2) a group of stakeholders with complementary expertise and key questions were identified; (3) a scientific review was conducted; (4) consensus on revisions was achieved; (5) guidelines were updated, reviewed widely, and approved. This multi-year process resulted in the consensus that regulatory agencies could consider additional endpoints, such as persistent HPV infection or immune equivalence, depending on the design of the HPV vaccine trials. Updating the guidelines will now accelerate vaccine development, reduce costs of clinical trials, and lead to faster regulatory approval.

Hemodynamically Significant Congenital Cardiac Lesions in Pregnancy

Opinion statementThe incidence of congenital cardiac disease among reproductive-aged women is increasing. Understanding the unique physiology of pregnancy and the postpartum period is critical to helping women achieve successful pregnancy outcomes. Risk assessment models estimate the cardiac, obstetric, and neonatal risks a woman may face and influence the conversations regarding pregnancy and contraception management. This review focuses on some of the most common congenital cardiac lesion encountered during pregnancy, as well as key aspects of antepartum, intrapartum, and postpartum care for these women. A multidisciplinary team, with Maternal-Fetal Medicine, Cardiology and Obstetric Anesthesiology specialists, is critical to the care of these patients.