Treating pregnant women with novel influenza A (H1N1)

Sep 1, 2009
By: Contemporary OB/GYN Staff
Contemporary OB/GYN

Treat pregnant women presenting with influenza-like illness with influenza antiviral
medications as soon as possible, without waiting for results of testing for influenza—if
testing is performed—according to new interim guidelines issued by the Centers for
Disease Control and Prevention (CDC).

The guidelines explain that pregnant women are likely to present as others with typical
acute respiratory influenza-like illness, including such symptoms as cough, sore throat,
rhinorrhea, and fever. Symptoms may also include body aches, headache, fatigue,
vomiting, and diarrhea. While most pregnant women will proceed to have a typical
uncomplicated course of the flu, illness can progress rapidly for a few, possibly becoming
complicated by a secondary bacterial infection, such as pneumonia, and/or causing fetal
distress. Adverse pregnancy outcomes and maternal deaths have been reported.

The currently circulating H1N1 flu is sensitive to the neuraminidase inhibitor antiviral
medications zanamivir (Relenza) and oseltamivir (Tamiflu). Because the former results in
lower systemic absorption than the latter, the latter is the drug of choice in pregnancy.
H1N1 is resistant to the adamantine antiviral medications, amantadine (Symmetrel) and
rimantadine (Flumadine).

Because pregnant women appear to be at higher risk for complications from the H1N1
flu, pregnancy is not a contraindication to these medications. Regimens recommended for
pregnant women are the same as those recommended for adults with seasonal flu.
Oseltamivir should be started as soon as possible after the onset of symptoms because
experience with seasonal flu indicates that benefits are greatest if the drug is started
within 48 hours of the onset of symptoms. However, if that window of opportunity
passes, experience with seasonal flu also indicates that the drug can provide benefit for
high-risk populations, including pregnant women, even when it is started more than 48
hours after the onset of symptoms.

Consider post-exposure antiviral chemoprophylaxis with zanamivir (because of its

limited systemic absorption) for pregnant women exposed to persons with suspected or
laboratory-confirmed H1N1 virus infection because maternal hyperthermia during the
first trimester doubles the risk of neural tube defects and may be associated with other
birth defects and adverse outcomes. Similarly, maternal fever during labor is associated
with numerous adverse neonatal and developmental outcomes.
Women should push when they feel the urge
Aug 1, 2009
By: Contemporary OB/GYN Staff
Contemporary OB/GYN

Allowing the fetus to passively descend the birth canal (i.e., passive descent) instead of
instructing women to push immediately upon full dilation has clear advantages for
healthy nulliparous women in the second stage of an uncomplicated labor who are using
epidural analgesia. This according to a recent meta-analysis of randomized controlled
trials.

The analysis, which includes seven studies involving almost 3,000 women, reveals that
passive descent, compared with early pushing, increases a woman's chance of having a
spontaneous vaginal birth by about 8% (RR, 1.08; 95% CI, 1.01–1.15; P=.025), decreases
the need for an instrument-assisted delivery by almost 25% (RR, 0.77; 95% CI, 0.77-
0.85; P≤.0001), and decreases pushing time by a mean difference of –0.19 hours (95%
CI, –0.27 to –0.12; P≤.0001).

Researchers found no significant differences in rates of cesarean delivery (RR, 0.80; 95%
CI, 0.57–1.12; P=.19), lacerations (RR, 0.88; 95% CI, 0.72–1.07; P=.20), or episiotomies
(RR, 0.97; 95% CI, 0.88–1.06; P=.45).

Brancato RM, Church S, Stone PW. A meta-analysis of passive descent versus immediate
pushing in nulliparous women with epidural analgesia in the second stage of labor. J
Obstet Gynecol Neonatal Nurs. 2008;37:4-12.

'Oral sex is not risk free...'

Aug 1, 2009
By: Contemporary OB/GYN Staff
Contemporary OB/GYN

...according to a fact sheet recently issued by the Centers for Disease Control and
Prevention (CDC). The sheet emphasizes that while the risk of transmitting human
immunodeficiency virus (HIV) through oral sex is much lower than that associated with
anal or vaginal sex, oral sex can still result in the transmission of HIV and other sexually
transmitted diseases (STDs), including herpes, syphilis, gonorrhea, genital warts (HPV),
intestinal parasites (amebiasis), and hepatitis A.
The sheet explains that many teens believe oral sex—defined as giving or receiving oral
stimulation to the penis, vagina, and/or anus—is safe. The CDC cites a national survey
conducted by the Kaiser Family Foundation that found that one in four sexually active
15- to 17-year-olds believes you cannot contract HIV by having unprotected oral sex;
another 15% are uncertain. Further, many teens do not consider oral sex to be sex at all.

Apart from abstinence, the best way to reduce the risk of transmission during oral sex,
according to the fact sheet, is to use a physical barrier, such as a dental dam or a condom,
the latter of which can be cut open for vaginal and anal contact, or left in tact for fellatio.
While at least one scientific article suggests that plastic food wrap is effective at
preventing the transmission of herpes simplex virus during oral-vaginal or oral-anal sex,
the jury is still out on whether it is effective at preventing the transmission of HIV or any
other STDs, and it is not manufactured or approved by the Food and Drug Administration
for this purpose.

News: Early bilateral oophorectomy increases cardiovascular mortality

May 1, 2009
By: Contemporary OB/GYN Staff
Contemporary OB/GYN

Removal of both of a woman's ovaries before age 45 increases her risk for death from
cardiovascular disease by about 44%, according to the findings of the Mayo Clinic Cohort
Study of Oophorectomy and Aging.

The study included 1,274 women with unilateral oophorectomy, 1,091 women with
bilateral oophorectomy, and 2,383 referent women.

While the women who received unilateral oophorectomy had a lower risk for
cardiovascular mortality than the referent women (HR 0.82; 95% CI; 0.67–0.99; P=.04),
those who received bilateral oophorectomy had an HR for death from cardiovascular
disease of 1.44 (95% CI; 1.01–2.05; P=.04). Furthermore, those who did not receive
estrogen replacement through age 45 years or longer were at even higher risk (HR 1.84;
95% CI; 1.27–2.68; P=.001), while those that did had an HR of 0.65 (95% CI; 0.30–1.41;
P=.28).

The authors of an accompanying editorial point out that early prophylactic

oophorectomy makes sense for a minority of women with genetic variants that greatly
increase their risk for ovarian cancer. But generally speaking, ovarian cancer causes about
15,000 women in the United States to die each year, while coronary heart disease causes
more than 300,000 deaths annually among US females, so the wisdom of routine
prophylactic oophorectomy performed before menopause should be carefully
reconsidered in the vast majority.

Rivera CM, Grossardt BR, Rhodes DJ, et al. Increased cardiovascular mortality after early
bilateral oophorectomy. Menopause. 2009;16:15-23. Parker WH, Manson JE.
Oophorectomy and cardiovascular mortality: is there a link? Menopause. 2009;16:1-2.