Ob.Gyn.
News
N EONATAL W ITHDRAWAL S YNDROME
VO L . 4 0 , N O. 6
Periodontitis may cause 18% of preterm, low-birth-weight
deliveries; treatment in the second trimester may lower that risk.
Periodontal Disease
Raises Preterm Risk
B Y B E T S Y B AT E S
Los Angeles Bureau
U N I V E R S A L C I T Y, C A L I F. —
Every prepregnancy consultation
should include a recommenda-
tion for a full periodontal exam-
ination, and patients should be
monitored throughout pregnan-
cy for signs of periodontal dis-
ease, Todd Hartsfield, D.D.S.,
recommended.
Evidence compiled from many
studies suggests that maternal
periodontal disease may be re-
sponsible for 18% of preterm,
low-birth-weight deliveries, he
said at a meeting of the Obstet-
rical and Gynecological Assem-
bly of Southern California.
Moreover, research suggests
that in patients with periodonti-
tis during the second trimester,
deep instrumental cleaning,
known among dentists as scaling
and root planing, may substan-
tially lower the risk of preterm
delivery.
Many of the studies detailing
periodontal risk have appeared
in dental journals that obstetri-
cians never see, said Dr. Harts-
field, director of the Dental Clin-
ical and Prevention Support
Center of the Inter Tribal Coun-
cil of Arizona in Phoenix.
“I’d like to see more interplay
between our professions,” Dr.
Hartsfield said during a special
lecture at the meeting.
“The dentist and dental hy-
www.eobg ynnews.com
T he Leading Inde p endent Ne wspaper for the Obstetrician/Gynecologist—Since 1966
gienist should be a part of the
health team that is involved in
caring for expectant mothers.”
He recommended several pa-
tient brochures offered by the
American Dental Association, in-
cluding “Women and Gum Dis-
ease,” “What is Scaling and Root
Planing?” and “Gum Disease:
The Warning Signs.”
Dr. Hartsfield also suggested
joint meetings of local dental and
ob.gyn. societies, and sessions in
which dentists and dental hy-
gienists could teach ob.gyn. nurs-
es and practitioners to conduct
“quick look” oral screenings dur-
ing each routine prenatal visit.
See Periodontal page 4
VITAL SIGNS
Medical Care Spending Outstrips Inflation
5%
Average Annual % Change in CPI
4%
3%
2%
1%
2000
Note: Based on Consumer Price Index (CPI) data from the Bureau of
Labor Statistics.
Source: Centers for Disease Control and Prevention
AND SSRI S , PAGE
INSIDE
Maternal Morbidity
Rises Sharply With
C OURTESY D R . M ARJORIE J EFFCOAT
Repeat Cesareans
Largest increase seen after fourth delivery.
Dr. Flamm’s BY ROBERT FINN
Clinical Pearls San Francisco Bureau
Contest R E N O , N E V. — Maternal
Win a portable DVD player! morbidity increases significantly
with each subsequent cesarean
PAGE 5
delivery, according to a large
prospective cohort study report-
ed by Robert M. Silver, M.D., at
The Rest the annual meeting of the Soci-
Of Your Life ety for Maternal-Fetal Medicine.
How physicians can fit Moreover, morbidity rates
exercise into a busy schedule. show a particularly large in-
PAGE 38
crease with the fourth and sub-
sequent cesarean deliveries, ac-
cording to the study, which was
based on data from the Maternal
Fetal Medicine Units (MFMU)
Network, created by the Na-
tional Institute of Child Health
and Human Development.
17P: Best for Prior Preterm
Flu Shot Births Before 34 Weeks
Study finds vaccine is safe
BY ROBERT FINN
and effective in second half San Francisco Bureau
of pregnancy.
PAGE 18 R E N O , N E V. — T herapy with
1 7
- hyd r ox y p r o g e s t e r o n e
caproate to prevent recurrent
preterm birth is associated with
an overall prolongation of preg-
nancy, especially in women with
a prior spontaneous birth before
34 weeks’ gestation, Catherine
Y. Spong, M.D., reported.
Weekly injections of 17
-hy-
droxyprogesterone caproate
(17P) was associated with an av-
erage pregnancy prolongation
K EVIN F OLEY, R ESEARCH /S ARAH L. G ALLANT, D ESIGN
of 1.5 weeks in women whose
Medical care earliest prior preterm birth was
All items
2001 2002 2003
21
MARCH 15, 2005
The central conclusion of this
study is that “the number of in-
tended pregnancies should be fac-
tored into consideration of pri-
mary elective cesarean delivery
or attempted vaginal birth after
cesarean,” said Dr. Silver of the
University of Utah, Salt Lake
City.
In addition, the study suggests
that physicians should give seri-
ous thought to a trial of labor in
women who are candidates for a
first cesarean delivery and who
are planning to have several
children.
Of the 378,168 births followed
prospectively by the 14 tertiary
care centers in the MFMU Net-
work, there was a total of 57,068
See Morbidity page 5
before 34 weeks’ gestation, she
said at the annual meeting of
the Society for Maternal-Fetal
Medicine.
Women whose earliest prior
preterm birth was between 34
and 37 weeks’ gestation exhibit-
ed a trend toward a statistically
significant prolongation of ges-
tation, but this did not reach sta-
tistical significance, according to
Dr. Spong of the National Insti-
tute of Child Health and Human
Development, Bethesda, Md.
The study involved a sec-
ondary analysis of a double-
masked, placebo-controlled trial
See 17P page 5
 M a r c h 1 5 , 2 0 0 5 • w w w. e o b g y n n e w s . c o m News 5

Repeat Cesareans Increase Risk Early West Nile Case May

Morbidity from page 1

cesarean deliveries. Dr. Silver’s study fo- creasing numbers of cesarean deliveries.
cused on the 30,132 cesarean deliveries that These included maternal death, deep ve-
Bode Ill for Western U.S.
were not accompanied by a trial of labor. nous thrombosis, pulmonary embolus, re-
More than 6,000 women who participated operation, endometritis, and wound de- B Y B E T S Y B AT E S a paralysis that can resemble polio.
in the study were having at least their third hiscence. Los Angeles Bureau “It doesn’t matter whether we’ve
cesarean delivery. And more than 1,800 Dr. Silver pointed out that previous had one case or five; if you see en-
women were having their smaller studies had suggested L O S A N G E L E S — The first human cephalitis or meningitis, you look for
fourth or more than fourth The study was that the rate of placenta acc- case of West Nile virus infection this West Nile virus,” said Laurene Masco-
cesarean delivery, making reta with placenta previa and year was diagnosed in Los Angeles in la, M.D., chief of the acute communi-
this by far the largest study carried out at one prior cesarean delivery early February, perhaps setting the cable disease control unit of Los An-
of its kind. tertiary care was about 25%. The MFMU stage for an early and virulent season geles County.
Several morbidities in- study suggests that this rate is for the far western United States. The first bird carrying the virus was
creased significantly with centers, so closer to 10% than 25%. Dr. “Since West Nile virus was [first] de- found in mid-January, whereas no bird
each subsequent cesarean participants are Silver cautioned that the tected in 1999, we’ve seen a lengthen- evidence was confirmed in California
delivery. (See table.) These morbidity rates in the ing period of transmission,” said Ned until the end of March in 2004. Twelve
included placenta accreta, not representative MFMU study should not be Hayes, M.D, of the Centers for Dis- birds in eight counties had been found
placenta previa, hysterecto- of the entire seen as an estimate of the ease Control and Prevention’s Division to have the virus by mid-February.
my, cystotomy, bowel in- true prevalence in the popu- of Vector-Borne Infectious Diseases Birds are a key player in the trans-
jury, ureteral injury, ileus, populaiton. lation at large. in Fort Collins, Colo. mission cycle of West Nile virus and are
need for a ventilator post- The study was carried out As the virus has spread south and carefully tracked, although mosquitoes
operatively, and transfusion of at least four in tertiary care centers that are likely to west across the United States, new are the direct vectors infecting humans.
units of blood. Increases were also seen in see an especially large proportion of com- “ecological dynamics” have influenced California and the Southwest, where
ICU admissions, operative time, and num- plicated pregnancies and cesarean deliv- transmission patterns, he explained. the disease struck hardest in 2004, have
ber of days in the hospital. eries, so the women who were included A wetter than normal winter in Cali- warmer climates than the northeastern
On the other hand, several morbidities in the study are not representative of the fornia and the Southwest may suit mos- states, where the virus first took hold
showed no significant increase with in- entire population. ■ quitoes well, meaning physicians will in the United States. Mosquito vectors
need to be especially alert to possible also differ, with Culex pipiens most com-
cases of the now reportable disease. mon in the Northeast and C. tarsalis
Complication Rates Increase With Number of Cesarean Deliveries The Los Angeles County Depart- and C. quinquefasciatus more often the
ment of Health Services announced an culprits in the West.
1 2 3 4 5 ³6
infection in an older man in east Los C. tarsalis was a common vector in
Placenta accreta 0.2% 0.3% 0.6% 2.1% 2.3% 6.7% Angeles County on Feb. 8. Colorado, where West Nile virus in-
Placenta accreta in As of mid-February, state and feder- fected 3,000 people in 2003, killing 63.
women with placenta previa 3.3% 11.0% 40.0% 61.0% 67.0% 67.0% al health officials had not completed “It’s a very efficient vector. It avidly
confirmatory tests on the case. bites humans and also bites birds, and it
Hysterectomy 0.6% 0.4% 0.9% 2.4% 3.5% 9.0%
Symptoms of the infection include seems to transmit the virus very well.”
Source: Dr. Silver fever, headache, fatigue, body aches, Dr. Hayes urged physicians to test for
skin rash, and swollen lymph nodes. West Nile virus and report any cases to
More serious manifestations of their state health departments, which,
West Nile encephalitis or meningitis in turn, notify the CDC.
Win a Portable DVD Player! also include neck stiffness, stupor, dis-
orientation, coma, tremors, convul-
West Nile virus infected 2,470 people
in 40 states in 2004, resulting in 88

I t’s time again for our annual Clinical Pearls

contest. This year we are awarding a portable
DVD player with car kit to nine lucky winners.
sions, and muscle weakness, as well as deaths.

Bruce L. Flamm, M.D., will select the top nine

entries, which will be featured in upcoming
columns. Progesterone Prolongs Gestation
So start thinking about those clinical tips that 17P from page 1
have helped you out over the years but aren’t
widely published. We’re looking for items that involving 463 women who were pregnant Dr. Spong commented during the meet-
can be summarized briefly. with singletons and had a documented pri- ing.
or preterm birth. Similarly, 4.6 women whose earliest pri-
Two Ways to Submit Your Entry On the basis of several studies, the or preterm birth was between 28 and 33.9
1. Drop off your pearls at the OB.GYN. NEWS American College of Obstetricians and weeks would require treatment to prevent
booth #529 at the annual meeting of the Ameri- Gynecologists in 2003 issued a committee one preterm birth.
can College of Obstetricians and Gynecologists in San Francisco May 9-11. opinion stating that 17P appears to prevent Although the study was not sufficient-
2. Send them to Dr. Flamm by preterm birth in a select ly powered to detect a sig-
Fax: 909-353-5625 group of high-risk women Unfortunately, nificant improvement in
E-mail: bruceflamm@aol.com with prior spontaneous preterm births among
Regular mail: 10445 Victoria Ave. preterm births (Obstet. Gy- many pharmacies women whose earliest prior
Riverside, CA 92503 necol. 2003;102:1115-6). do not routinely preterm birth was between
Unfortunately, many 34 and 36.9 weeks’ gestation,
Multiple submissions are permitted. Dr. Flamm will select what he considers to pharmacies do not rou- stock this form of Dr. Spong calculated that
be the nine most clinically useful and concisely presented pearls. All decisions tinely stock this form of progesterone. As one would need to treat 7.2
are final. The prize-winning pearls will be published in Dr. Flamm’s Clinical progesterone. As a result, women in this group to pre-
Pearls column beginning in the July 15, 2005, issue of OB.GYN. NEWS. Other sub- it can be very difficult to a result, it can be vent one preterm birth.
missions may be published in subsequent columns. obtain. very difficult These number-needed-to-
All entries must be received by May 15, 2005. Dr. Spong’s logistic re- treat values compare favor-
gression model adjusted for to obtain. ably with other common
Visit Dr. Flamm at our booth at the race, gestational age at ran- risk-avoidance recommen-
ACOG annual meeting in San Francisco. domization, and having at least two prior dations. For example, one needs to treat
Where: Exhibit Hall, OB.GYN. NEWS Booth #529 spontaneous preterm births. 102 people with low-dose aspirin to pre-
When: Monday, May 9, 11 a.m. to 12 p.m. A physician would have to treat 4.7 vent a single cardiovascular incident, and
Tuesday, May 10, 11 a.m. to 12 p.m. women whose earliest prior preterm 42 patients with prior MI with  -blockers
birth was between 20 and 27.9 weeks’ to prevent a single cardiac death, Dr.
gestation to prevent one preterm birth, Spong said. ■