The classic symptoms of myocardial infarction, or heart attack, are chest pain or pressure, shortness of breath, diaphoresis (sweating), nausea, and weakness. Yet according to a review of the National Registry of Myocardial Infarction of over a million heart attack victims from 1994 to 2006, young women were much more likely to present WITHOUT CHEST PAIN than men. And young women were more likely to die. This may be partly because of a delay in diagnosis since the symptoms were atypical, and thus a delay in reperfusion therapy (drugs called “clotbusters” to open up coronary arteries, or procedures to open such as balloon angioplasty with or without coronary artery stents). The study was published by Dr. John Canto and colleagues in this week’s Journal of the American Medical Association, entitled “Association of Age and Sex with Myocardial Infarction Symptom Presentation and In-Hospital Mortality.” One finding was that 42% of women never experience the classic heart attack symptom of chest pain or pressure (compared to 31% of men). Another finding was that 15% of female heart attack patients die in the hospital, compared to 10% of men
Previous articles had suggested that a history of Loop Electrosurgical Excision Procedure (or LEEP) increased the baseline risk of 10% for preterm birth to 15%, and that the risk of midpregnancy loss (“incompetent cervix”) might be as high as 2% after LEEP. LEEP is a procedure used to treat precancerous abnormalities of the cervix for the prevention of cervical cancer. It is generally done after a colposcopy has confirmed the findings of an abnormal pap smear. LEEP has the advantage over purely destructive therapies such as laser ablation or cryotherapy in that it removes a specimen which gives the pathologist a second chance to ensure that no actual cancer was missed, i.e. only precancerous tissue is found, and that a margin of normal tissue surrounds the abnormal tissue, i.e the entire abnormality was removed.
The good news presented at a recent meeting of the Society for Maternal Fetal Medicine is that LEEP does not increase either the risk of pregnancy loss or of preterm birth. The research was done at Washington University in St Louis by Dr. George Macones and colleagues. Their data is able to contradict the earlier conclusions because previous researchers failed to control for other risk factors. Instead of comparing patients who had LEEP done to women who had never had an abnormal pap smear, Dr. Macones and colleagues controlled for these confounding variables. They compared women undergoing LEEP to women who had undergone cervical punch biopsy for abnormal pap smears. Birth before 34 weeks was 7.3% in the women who underwent LEEP, compared to 7.7% in those who had undergone punch biopsy alone. Dr. Macones concluded that patients with a history of LEEP “do not require increased surveillance during pregnancy.”
http://www.saladltd.co.uk/info/ES/EffortlessEvolutionBookMain.pdf
In his wonderful little book “Effortless Evolution: A New Paradigm for Personal Change,” (available online for free via the above link) Jamie Smart explains how a sense of well-being is not dependent on our circumstances. It is, in fact, innate and available to all of us at all times. Drawing on the work of Sydney Banks (“The Enlightened Gardner” and “The Missing Link”) and inventor R Buckminster Fuller among many others, Jamie shows us how we can “effortlessly” evolve to accessing this inner sense of well-being at any time, and how feelings of anxiety alert us that our thinking is distorted at times. We all have found how achieving a goal or obtaining something brings that sense of well-being, or happiness, but that it is temporary. Just as an improvement in our circumstances cannot provide us with permanent well-being, neither can a lack of achieving our desires withhold that well-being from us. Of course we will always want things, new talents, new knowledge, new experiences. But there is never a need to be anxious and discontent because we haven’t obtained them yet.
A paper presented yesterday at a meeting of the Society for Maternal Fetal Medicine reviewed the common practice of using cesarean section when babies needed to be delivered early because of poor growth. It was thought that a more atraumatic birth may benefit these babies, i.e. avoiding the stress of labour. This would seem to make sense as these babies often have placental problems contributing to their poor growth. An unhealthy placenta can make labour more dangerous for a fetus. But after reviewing 2,560 births of babies delivered before 34 weeks gestation because of poor growth (small-for-gestational age), the finding was that those delivered by cesarean section had more breathing difficulties than those born vaginally. The decreased oxygenation from poor breathing can worsen other problems of prematurity including jaundice, feeding difficulties, and adversely affect brain development. So consideration for delivering these patients vaginally would now seem reasonable, or even preferable. Of course, some preemie babies will still need to be delivered by cesarean section for breech presentation, placenta previa, fetal heart rate decelerations during labor, etc.
In an article entitled “Pelvic Floor Disorders after vaginal birth,” published in the February,2012 issue of Obstetrics and Gynecology Drs Victoria Handl et al review the effects of episiotomy, vaginal lacerations, and forceps delivery. Participants in the study were recruited 5-10 years after delivery of their first child. Pelvic floor disorders in the 449 women included stress incontinence (16%), overactive bladder (12%), anal incontinence (4%), and prolapse (14%). Prolapse was only considered if it extended all the way to the hymen or beyond. The authors found almost a 3-fold increased risk of overactive bladder and almost a doubling of prolapse with a history of forceps delivery. Also, women with multiple lacerations of the perineum were twice as likely to have prolapse. Interestingly, the authors did not find an increase of these complications with episiotomy. They point out in their discussion that they are aware of three other published articles that do suggest episiotomy increases pelvic floor disorders. It simply was not found in this particular study. As one textbook author wrote, “the medical literature is confusing.” I.e. studies often come to different conclusions.
You may recall that my very first post on this blog (“Episiotomy not routinely indicated”) discussed the fact that episiotomy did not protect against a laceration extending into the anal sphincter or rectum, but rather increased those risks. That still stands, i.e. this article does not contradict that statement. That post also mentioned that episiotomy did not protect against pelvic prolapse. The authors of this new article do not claim that episiotomy protects against prolapse – they just didn’t find an association, or a suggestion that episiotomy caused prolapse. Neither did they claim that multiple lacerations cause prolapse (suggesting that if one avoided multiple lacerations by doing more episiotomies, prolapse might be preventable). Instead, they concluded that “We speculate that spontaneous perineal laceration may be a marker of excessive stretch at the time of delivery.”
The biggest conclusion of the article, however, was that forceps delivery is associated with pelvic floor disorders. This would be one more thing to consider if operative delivery becomes necessary and one is deciding between cesarean and forceps deliveries.
Benjamin Franklin said “If you love life, don’t waste time, as that is what life is made of.” In his presidential address to the Central Association of Obstetricians and Gynecologists two years ago, Dr. Dennis Lutz advised the physicians attending the meeting to gain control of their lives via time management. His address was published in the March,2010 issue of The American Journal of Obstetrics and Gynecology under the title “The time in your life: use it wisely.” Dr. Lutz listed 13 time management skills as follows:
1. Time chart a week in your life
2. Plan each day in advance
3. Make to-do lists manageable
4. Learn to delegate
5. Multitasking: pro or con?
6. Control commitments
7. Do not waste time worrying
8. Reduce clutter in your life
9. Master the circular theory of managing daily tasks
10. Sleep: the neglected one-third of our lives
11. Avoid starting over and the 4 year cycle
12. Build private time into every day
13. Protect your health
Dr. Lutz then went into a meaningful discussion of each recommendation. Although the talk was aimed at physicians, I think most of the points and advice could be beneficial to almost everyone. For example for item number one, he points out that although most of us think we know which things we spend the most time on, we “should not let these ‘guesstimates’ deceive [us].” By literally recording what we are doing for each 15 minute block for one full week of our lives, we can see exactly how much time we really spend sleeping, working, eating, commuting, using the computer and telephone, watching TV, etc. He points out that 7 hours sleeping, 11 hours working, 4 hours for daily tasks would account for 22 hours of the day. That leaves only 2 hours discretionary time, so even finding a single extra hour per day would represent a 50% gain!
Re: 2: plan each day in advance: although emergencies will arise and plans will always have to be changed, waiting until the day begins is too late. Planning the next day the night before alleviates some of the morning chaos that comes with work and family commitments
3.Make to-do lists manageable: minimize interruptions; avoid distractions; divide big projects into a series of smaller tasks
4.Learn to delegate
5. Multitasking: pro or con? Dr. Lutz says “In truth, very few people (approximately 10%) actually can focus on >1 significant task at a time. . . Almost always, intense sequential focusing on 1 task at a time increases efficiency for everyone.”
6. Control commitments: we all know this one: it’s learning to say no! (when we are already overwhelmed)
7. Do not waste time worrying. So many of the things people worry about are things upon which our actions cannot have any effect! There is no bigger waste than the time we spend worrying about such things
8. Reduce the clutter in your life. For Ben Franklin, this was #3 on the characteristics he was trying to achieve, but even he was not satisfied with the progress he made towards this goal. Clutter wastes time through inefficiency and is a major distraction
9. Master the circular theory of managing daily tasks. Dr. Lutz explains that in theory we could return home after each task at work, but obviously this would be inefficient. Of course we may not be able to go from home to hospital rounds to surgery to the office, and finish the office just before heading home, BECAUSE a delivery may require going BACK to the hospital (or emergency surgery may require that) before returning to finish the office. BUT, the more we can get everything done in one place before moving to the next place, and then back home, the more efficient we are.
10. Sleep: I’ve posted about this before. We simply cannot function as well with inadequate sleep, and will pay the price in the long run if we don’t find a way to accommodate this need
11. Avoid starting over and the four year cycle: This refers to doctors looking back and seeing their lives in four year chunks – four years of college, four years of med school, four years of residency (3-5 anyway), sometimes a 4 year subspecialty fellowship (or 3), then for many a four year stent in the military or Public Health Service to pay back for medical school – and then when it’s time to settle down in a 25-35 year career practice, not being able to keep from changing jobs again in four years!
12. Build private time into every day. For some the only time to really think peacefully is during a long commute in their car. Meditating (see the post on “The Relaxation Response” by Dr. Benson) is a way for others
13. Protect your health: For reducing anxiety, improving sleep, and functioning more efficiently at home and at work, there is nothing like a regular exercise program.
The Norwegian Mother and Child Cohort Study (nicknamed MoBa) was a prospective, observational study which recruited pregnant women from 1999 to 2008. In October 2011 in the “Journal of the American Medical Associaton” data was published on the association of mom’s folic acid intake during pregnancy and the incidence of severe language delay in their children. A total of 38,954 children were included. 204 or 0.5% had severe language delay, based on the 3 year follow up questionnaires received by June, 2010. In moms who took folic acid, the incidence of severe language delay was 0.4%, whereas in those who did not take folic acid, there was a 0.9% incidence. This was a statistically significant difference. Unlike the United States, Norway does not mandate that folic acid be added to all cereals, breads, flours, and pastas, so this is an ideal population in which to study the effects of added folate. Yet another reason to supplement with folic acid during pregnancy.
In women whose last delivery occurred before 37 weeks gestation, receiving weekly injections of 17 hydroxyprogesterone caproate from 15 to 35 weeks has been proven to reduce the risk of recurrent preterm birth in the current pregnancy (see also September 4th’s post). Newer studies show that vaginal progesterone preparations likewise reduce the risk of preterm birth in at-risk patients. Studies in 2011 published in Obstetrics and Gynecology by Berghalla et al and in Ultrasound in Obstetrics and Gynecology by Hassan et al look at when these therapies are effective relative to the patient’s cervical length at mid-pregnancy, as well as their history of prior preterm birth. These articles and others were reviewed by Drs John Repke and Jaimey Pauli in this month’s issue of OBG Management. The study by Hassan, a large, randomized, controlled trial of universal screening with cervical length found that in those with cervical length less than 20 mm, supplementing with vaginal progesterone gel reduced the risk of birth prior to 33 weeks by 45%. On the other hand, for those with BOTH a short cervix AND a history of previous preterm birth, progesterone was not effective. But the study by Berghalla found that cervical cerclage reduced the risk of preterm birth with both of these risk factors. We have been routinely measuring cervical length at the time of our patients’ midpregnancy routine sonograms, but have to admit that it is controversial. Not all agree that such routine screening is an effective or cost-effective way to prevent preterm birth. Dr. Carl Weiner, chairman of ObGyn at Kansas University Medical Center has for years been recommending cervical length measurements at 20-23 weeks and supplement those with a short cervix with progesterone.
So to conclude: with a history of preterm birth, progesterone. For a shortened cervical length, progesterone. For a shortened cervical length AND a history of preterm birth, cervical cerclage.
Of course, continued research on these issues is needed to confirm this approach
Dr Jeffrey Peipert and colleagues enrolled 5,087 women in the St Louis area who did not want to become pregnant in a year-long study of satisfaction and continuation rates of various contraceptives. Their primary purpose was to compare long-acting contraception such as either of two IUDs or a subdermal implant (Implanon) to routine contraception such as birth control pills, the patch, the vaginal ring (NuvaRing), and DepoProvera. The authors found the highest rates of continuation of use for the levonorgestrel IUD, or Mirena, of 88% and the copper IUD (Paragard) of 84% at the end of 12 months. Implanon was close behind with 83% of women who started with it continuing it at the end of 12 months. Conversely, of the methods the authors classified as “non-long-acting,” continuation rates were 57% for DepoProvera, 55% for birth control pills, 54% for the ring and 49% for the patch. Satisfaction rates followed the same pattern with 80% of women satisfied with their IUDs and 79% of those who used the implant satisfied, while only 53% of the “non-long-acting” methods were satisfied with their method of birth control. The authors concluded that, because they are the most effective forms of reversible contraception AND because they have higher satisfaction rates and user continuation rates, the IUDs and the implant should be considered first in women who do not want to conceive a child in the near future
