OBG Management

For many decades the limit of viability was believed to be approximately 24 weeks of gestation. In many medical centers, newborns delivered at less than 25 weeks are evaluated in the delivery room and the decision to resuscitate is based on the infant’s clinical response. In the past, aggressive and extended resuscitation of newborns at 22 and 23 weeks was not common because the prognosis was bleak and clinicians did not want to inflict unnecessary pain when the chances for survival were limited. Recent advances in obstetric and pediatric care, however, have resulted in the survival of some infants born at 22 weeks’ gestation, calling into question long-held beliefs about the limits of viability.

In 2 recent reports, investigators used data from the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network to acquire detailed information about newborn survival and morbidity at 22 through 28 weeks’ gestation (TABLES 1 and 2).^1,2 These data show that the survival of newborns at 23 through 27 weeks’ gestation is increasing, albeit slowly. Survival, without major morbidity, is gradually improving for newborns at 25 through 28 weeks.^1,2 But what is the prognosis for a fetus born at 22 or 23 weeks?

There are several aspects of this issue to consider, including accurate dating of the gestational age and current viability outcomes data.

Determining the limit of viability: Accurate dating is essentialThe limit of viability is the milestone in gestation when there is a high probability of extrauterine survival. A major challenge in studies of the limit of viability for newborns is that accurate gestational dating is not always available. For example, in recent reports from the NICHD Neonatal Research Network the gestational age was determined by the best obstetric estimate, or the Ballard or Dubowitz examination, of the newborn.^1,2

It is well known that ultrasound dating early in gestation is a better estimate of gestational age than last menstrual period, uterine sizing, or pediatric examination of the newborn. Hence, the available data are limited by the absence of precise gestational dating with early ultrasound. Data on the limit of viability with large numbers of births between 22 and 24 weeks with early ultrasound dating would help to refine our understanding of the limit of viability.

At 23 weeks, each day of in utero development is criticalThe importance of each additional day spent in utero during the 23rd week of gestation was demonstrated in a small cohort in 2001.⁴ Overall, during the 23rd week of gestation the survival of newborns to discharge was 33%.⁴ This finding is similar to the survival rate reported by the NICHD Neonatal Research Network in 2012.¹ However, survival was vastly different early, compared with later, in the 23rd week⁴:

• from 23 weeks 0 days to 23 weeks 2 days: no newborn survived
• at 23 weeks 3 days and 23 weeks 4 days: 40% of newborns survived
• at 23 weeks 5 days and 23 weeks 6 days: 63% of newborns survived (a similar survival rate of 24-week gestations was reported by the NICHD Neonatal Research Network¹).

The development of the fetus across the 23rd week of gestation appears to be critical to newborn survival. Hence, every day of in utero development during the 23rd week is critically important. A great challenge for obstetricians is how to approach the woman with threatened preterm birth at 22 weeks 0 days’ gestation. If the woman delivers within a few days, the likelihood of survival is minimal. However, if the pregnancy can be extended to 23 weeks and 5 days, survival rates increase significantly.

Aligning the actions of birth team, mother, and familyFactors that influence the limit of viability include:

• gestational age
• gender of the fetus (Females are more likely than males to survive.)
• treatment of the mother with glucocorticoids prior to birth
• newborn weight.

To increase the likelihood of newborn survival, obstetricians need to treat women at risk for preterm birth with antenatal glucocorticoids and antibiotics for rupture of membranes and to limit fetal stress during the birth process. Guidelines have evolved to encourage clinicians to treat women at preterm birth risk with glucocorticoids either at:

• 23 weeks’ gestation or
• 22 weeks’ gestation, if birth is anticipated to occur at 23 weeks or later.⁵

At birth, pediatricians are then faced with the very difficult decision of whether or not to aggressively resuscitate the severely preterm infant. Complex medical, social, and ethical issues ultimately guide pediatricians’ actions in this challenging situation. It is important for their actions to be in consensus with the obstetrician, the mother, and the mother’s family and for a consensus to be reached. Dissonant plans may increase adverse outcomes for the newborn. In one study when pediatricians and obstetricians were not aligned in their actions, the risk of death of an extremely preterm newborn significantly increased.⁶

Prior to birth, team meetings that include the obstetricians, pediatricians, mother, and family will help to set expectations about the course of care and, in turn, improve perceived outcomes.⁵ If feasible, obstetricians and pediatricians should develop joint institutional guidelines about the general approach to pregnant women when birth may occur at 22 or 23 weeks’ gestation.⁵

Is aggressive management of preterm birth and neonatal resuscitation a self-fulfilling prophecy?The beliefs and training of clinicians may influence the outcome of extremely preterm newborns. For example, if obstetricians and pediatricians focus on the fact that birth at 23 weeks is not likely to result in survival without severe morbidity, they may withhold key interventions such as antenatal glucocorticoids, antibiotics for rupture of the membranes, and aggressive newborn resuscitation.⁷ Consequently the likelihood of survival may be reduced.

If clinicians believe in maximal interventions for all newborns at 22 and 23 weeks’ gestation, their actions may result in a small increase in newborn survival—but at the cost of painful and unnecessary interventions in many newborns who are destined to die. Finding the right balance along the broad spectrum from expectant management to aggressive and extended resuscitation is challenging. Clearly there is no “right answer” with these extremely difficult decisions.

Future trends in the limit of viabilityIn 1963, Jacqueline Bouvier Kennedy, at 34 weeks’ gestation, went into preterm labor and delivered her son Patrick at a community hospital. Patrick developed respiratory distress syndrome and was transferred to the Boston Children’s Hospital. He died shortly thereafter.⁸ Would Patrick have survived if he had been delivered at an institution capable of providing high-risk obstetric and newborn services? Would such modern interventions as antenatal glucocorticoids, antibiotics for ruptured membranes, liberal use of cesarean delivery, and aggressive neonatal resuscitation have improved his chances for survival?

From our current perspective, it is surprising that a 34-week newborn died shortly after birth. With modern obstetric and pediatric care that scenario is unusual. It is possible that future advances in medical care will push the limit of viability to 22 weeks’ gestation. Future generations of clinicians may be surprised that the medicine we practice today is so limited.

However, given our current resources, it is unlikely that newborns at 22 weeks’ gestation will survive, or survive without severe morbidity. Consequently, routine aggressive resuscitation of newborns at 22 weeks should be approached with caution. At 23 weeks and later, many newborns will survive and a few will survive without severe morbidity. Given the complexity of the issues, the approach to resuscitation of infants at 22 and 23 weeks must account for the perspectives of the birth mother and her family, obstetricians, and pediatricians. Managing threatened preterm birth at 22 and 23 weeks is one of our greatest challenges as obstetricians, and we need to meet this challenge with grace and skill.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

For many decades the limit of viability was believed to be approximately 24 weeks of gestation. In many medical centers, newborns delivered at less than 25 weeks are evaluated in the delivery room and the decision to resuscitate is based on the infant’s clinical response. In the past, aggressive and extended resuscitation of newborns at 22 and 23 weeks was not common because the prognosis was bleak and clinicians did not want to inflict unnecessary pain when the chances for survival were limited. Recent advances in obstetric and pediatric care, however, have resulted in the survival of some infants born at 22 weeks’ gestation, calling into question long-held beliefs about the limits of viability.

In 2 recent reports, investigators used data from the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network to acquire detailed information about newborn survival and morbidity at 22 through 28 weeks’ gestation (TABLES 1 and 2).^1,2 These data show that the survival of newborns at 23 through 27 weeks’ gestation is increasing, albeit slowly. Survival, without major morbidity, is gradually improving for newborns at 25 through 28 weeks.^1,2 But what is the prognosis for a fetus born at 22 or 23 weeks?

There are several aspects of this issue to consider, including accurate dating of the gestational age and current viability outcomes data.

Determining the limit of viability: Accurate dating is essentialThe limit of viability is the milestone in gestation when there is a high probability of extrauterine survival. A major challenge in studies of the limit of viability for newborns is that accurate gestational dating is not always available. For example, in recent reports from the NICHD Neonatal Research Network the gestational age was determined by the best obstetric estimate, or the Ballard or Dubowitz examination, of the newborn.^1,2

It is well known that ultrasound dating early in gestation is a better estimate of gestational age than last menstrual period, uterine sizing, or pediatric examination of the newborn. Hence, the available data are limited by the absence of precise gestational dating with early ultrasound. Data on the limit of viability with large numbers of births between 22 and 24 weeks with early ultrasound dating would help to refine our understanding of the limit of viability.

At 23 weeks, each day of in utero development is criticalThe importance of each additional day spent in utero during the 23rd week of gestation was demonstrated in a small cohort in 2001.⁴ Overall, during the 23rd week of gestation the survival of newborns to discharge was 33%.⁴ This finding is similar to the survival rate reported by the NICHD Neonatal Research Network in 2012.¹ However, survival was vastly different early, compared with later, in the 23rd week⁴:

• from 23 weeks 0 days to 23 weeks 2 days: no newborn survived
• at 23 weeks 3 days and 23 weeks 4 days: 40% of newborns survived
• at 23 weeks 5 days and 23 weeks 6 days: 63% of newborns survived (a similar survival rate of 24-week gestations was reported by the NICHD Neonatal Research Network¹).

The development of the fetus across the 23rd week of gestation appears to be critical to newborn survival. Hence, every day of in utero development during the 23rd week is critically important. A great challenge for obstetricians is how to approach the woman with threatened preterm birth at 22 weeks 0 days’ gestation. If the woman delivers within a few days, the likelihood of survival is minimal. However, if the pregnancy can be extended to 23 weeks and 5 days, survival rates increase significantly.

Aligning the actions of birth team, mother, and familyFactors that influence the limit of viability include:

• gestational age
• gender of the fetus (Females are more likely than males to survive.)
• treatment of the mother with glucocorticoids prior to birth
• newborn weight.

To increase the likelihood of newborn survival, obstetricians need to treat women at risk for preterm birth with antenatal glucocorticoids and antibiotics for rupture of membranes and to limit fetal stress during the birth process. Guidelines have evolved to encourage clinicians to treat women at preterm birth risk with glucocorticoids either at:

• 23 weeks’ gestation or
• 22 weeks’ gestation, if birth is anticipated to occur at 23 weeks or later.⁵

At birth, pediatricians are then faced with the very difficult decision of whether or not to aggressively resuscitate the severely preterm infant. Complex medical, social, and ethical issues ultimately guide pediatricians’ actions in this challenging situation. It is important for their actions to be in consensus with the obstetrician, the mother, and the mother’s family and for a consensus to be reached. Dissonant plans may increase adverse outcomes for the newborn. In one study when pediatricians and obstetricians were not aligned in their actions, the risk of death of an extremely preterm newborn significantly increased.⁶

Prior to birth, team meetings that include the obstetricians, pediatricians, mother, and family will help to set expectations about the course of care and, in turn, improve perceived outcomes.⁵ If feasible, obstetricians and pediatricians should develop joint institutional guidelines about the general approach to pregnant women when birth may occur at 22 or 23 weeks’ gestation.⁵

Is aggressive management of preterm birth and neonatal resuscitation a self-fulfilling prophecy?The beliefs and training of clinicians may influence the outcome of extremely preterm newborns. For example, if obstetricians and pediatricians focus on the fact that birth at 23 weeks is not likely to result in survival without severe morbidity, they may withhold key interventions such as antenatal glucocorticoids, antibiotics for rupture of the membranes, and aggressive newborn resuscitation.⁷ Consequently the likelihood of survival may be reduced.

If clinicians believe in maximal interventions for all newborns at 22 and 23 weeks’ gestation, their actions may result in a small increase in newborn survival—but at the cost of painful and unnecessary interventions in many newborns who are destined to die. Finding the right balance along the broad spectrum from expectant management to aggressive and extended resuscitation is challenging. Clearly there is no “right answer” with these extremely difficult decisions.

Future trends in the limit of viabilityIn 1963, Jacqueline Bouvier Kennedy, at 34 weeks’ gestation, went into preterm labor and delivered her son Patrick at a community hospital. Patrick developed respiratory distress syndrome and was transferred to the Boston Children’s Hospital. He died shortly thereafter.⁸ Would Patrick have survived if he had been delivered at an institution capable of providing high-risk obstetric and newborn services? Would such modern interventions as antenatal glucocorticoids, antibiotics for ruptured membranes, liberal use of cesarean delivery, and aggressive neonatal resuscitation have improved his chances for survival?

From our current perspective, it is surprising that a 34-week newborn died shortly after birth. With modern obstetric and pediatric care that scenario is unusual. It is possible that future advances in medical care will push the limit of viability to 22 weeks’ gestation. Future generations of clinicians may be surprised that the medicine we practice today is so limited.

However, given our current resources, it is unlikely that newborns at 22 weeks’ gestation will survive, or survive without severe morbidity. Consequently, routine aggressive resuscitation of newborns at 22 weeks should be approached with caution. At 23 weeks and later, many newborns will survive and a few will survive without severe morbidity. Given the complexity of the issues, the approach to resuscitation of infants at 22 and 23 weeks must account for the perspectives of the birth mother and her family, obstetricians, and pediatricians. Managing threatened preterm birth at 22 and 23 weeks is one of our greatest challenges as obstetricians, and we need to meet this challenge with grace and skill.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

For many decades the limit of viability was believed to be approximately 24 weeks of gestation. In many medical centers, newborns delivered at less than 25 weeks are evaluated in the delivery room and the decision to resuscitate is based on the infant’s clinical response. In the past, aggressive and extended resuscitation of newborns at 22 and 23 weeks was not common because the prognosis was bleak and clinicians did not want to inflict unnecessary pain when the chances for survival were limited. Recent advances in obstetric and pediatric care, however, have resulted in the survival of some infants born at 22 weeks’ gestation, calling into question long-held beliefs about the limits of viability.

In 2 recent reports, investigators used data from the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network to acquire detailed information about newborn survival and morbidity at 22 through 28 weeks’ gestation (TABLES 1 and 2).^1,2 These data show that the survival of newborns at 23 through 27 weeks’ gestation is increasing, albeit slowly. Survival, without major morbidity, is gradually improving for newborns at 25 through 28 weeks.^1,2 But what is the prognosis for a fetus born at 22 or 23 weeks?

There are several aspects of this issue to consider, including accurate dating of the gestational age and current viability outcomes data.

Determining the limit of viability: Accurate dating is essentialThe limit of viability is the milestone in gestation when there is a high probability of extrauterine survival. A major challenge in studies of the limit of viability for newborns is that accurate gestational dating is not always available. For example, in recent reports from the NICHD Neonatal Research Network the gestational age was determined by the best obstetric estimate, or the Ballard or Dubowitz examination, of the newborn.^1,2

It is well known that ultrasound dating early in gestation is a better estimate of gestational age than last menstrual period, uterine sizing, or pediatric examination of the newborn. Hence, the available data are limited by the absence of precise gestational dating with early ultrasound. Data on the limit of viability with large numbers of births between 22 and 24 weeks with early ultrasound dating would help to refine our understanding of the limit of viability.

At 23 weeks, each day of in utero development is criticalThe importance of each additional day spent in utero during the 23rd week of gestation was demonstrated in a small cohort in 2001.⁴ Overall, during the 23rd week of gestation the survival of newborns to discharge was 33%.⁴ This finding is similar to the survival rate reported by the NICHD Neonatal Research Network in 2012.¹ However, survival was vastly different early, compared with later, in the 23rd week⁴:

• from 23 weeks 0 days to 23 weeks 2 days: no newborn survived
• at 23 weeks 3 days and 23 weeks 4 days: 40% of newborns survived
• at 23 weeks 5 days and 23 weeks 6 days: 63% of newborns survived (a similar survival rate of 24-week gestations was reported by the NICHD Neonatal Research Network¹).

The development of the fetus across the 23rd week of gestation appears to be critical to newborn survival. Hence, every day of in utero development during the 23rd week is critically important. A great challenge for obstetricians is how to approach the woman with threatened preterm birth at 22 weeks 0 days’ gestation. If the woman delivers within a few days, the likelihood of survival is minimal. However, if the pregnancy can be extended to 23 weeks and 5 days, survival rates increase significantly.

Aligning the actions of birth team, mother, and familyFactors that influence the limit of viability include:

• gestational age
• gender of the fetus (Females are more likely than males to survive.)
• treatment of the mother with glucocorticoids prior to birth
• newborn weight.

To increase the likelihood of newborn survival, obstetricians need to treat women at risk for preterm birth with antenatal glucocorticoids and antibiotics for rupture of membranes and to limit fetal stress during the birth process. Guidelines have evolved to encourage clinicians to treat women at preterm birth risk with glucocorticoids either at:

• 23 weeks’ gestation or
• 22 weeks’ gestation, if birth is anticipated to occur at 23 weeks or later.⁵

At birth, pediatricians are then faced with the very difficult decision of whether or not to aggressively resuscitate the severely preterm infant. Complex medical, social, and ethical issues ultimately guide pediatricians’ actions in this challenging situation. It is important for their actions to be in consensus with the obstetrician, the mother, and the mother’s family and for a consensus to be reached. Dissonant plans may increase adverse outcomes for the newborn. In one study when pediatricians and obstetricians were not aligned in their actions, the risk of death of an extremely preterm newborn significantly increased.⁶

Prior to birth, team meetings that include the obstetricians, pediatricians, mother, and family will help to set expectations about the course of care and, in turn, improve perceived outcomes.⁵ If feasible, obstetricians and pediatricians should develop joint institutional guidelines about the general approach to pregnant women when birth may occur at 22 or 23 weeks’ gestation.⁵

Is aggressive management of preterm birth and neonatal resuscitation a self-fulfilling prophecy?The beliefs and training of clinicians may influence the outcome of extremely preterm newborns. For example, if obstetricians and pediatricians focus on the fact that birth at 23 weeks is not likely to result in survival without severe morbidity, they may withhold key interventions such as antenatal glucocorticoids, antibiotics for rupture of the membranes, and aggressive newborn resuscitation.⁷ Consequently the likelihood of survival may be reduced.

If clinicians believe in maximal interventions for all newborns at 22 and 23 weeks’ gestation, their actions may result in a small increase in newborn survival—but at the cost of painful and unnecessary interventions in many newborns who are destined to die. Finding the right balance along the broad spectrum from expectant management to aggressive and extended resuscitation is challenging. Clearly there is no “right answer” with these extremely difficult decisions.

Future trends in the limit of viabilityIn 1963, Jacqueline Bouvier Kennedy, at 34 weeks’ gestation, went into preterm labor and delivered her son Patrick at a community hospital. Patrick developed respiratory distress syndrome and was transferred to the Boston Children’s Hospital. He died shortly thereafter.⁸ Would Patrick have survived if he had been delivered at an institution capable of providing high-risk obstetric and newborn services? Would such modern interventions as antenatal glucocorticoids, antibiotics for ruptured membranes, liberal use of cesarean delivery, and aggressive neonatal resuscitation have improved his chances for survival?

From our current perspective, it is surprising that a 34-week newborn died shortly after birth. With modern obstetric and pediatric care that scenario is unusual. It is possible that future advances in medical care will push the limit of viability to 22 weeks’ gestation. Future generations of clinicians may be surprised that the medicine we practice today is so limited.

However, given our current resources, it is unlikely that newborns at 22 weeks’ gestation will survive, or survive without severe morbidity. Consequently, routine aggressive resuscitation of newborns at 22 weeks should be approached with caution. At 23 weeks and later, many newborns will survive and a few will survive without severe morbidity. Given the complexity of the issues, the approach to resuscitation of infants at 22 and 23 weeks must account for the perspectives of the birth mother and her family, obstetricians, and pediatricians. Managing threatened preterm birth at 22 and 23 weeks is one of our greatest challenges as obstetricians, and we need to meet this challenge with grace and skill.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

This recently published study from Finland generated headlines when its authors concluded that stopping HT elevates the risk of mortality from cardiovascular disease (CVD), including cardiac and cerebrovascular events. Using nationwide data, investigators compared the CVD mortality rate among women who discontinued HT during the years 1994 through 2009 (n = 332,202) with expected (not actual) CVD mortality rates in the background population.
Within the first year after HT discontinuation, elevations in death rates from cardiac events and stroke were noted (standardized mortality ratio, 1.26 and 1.63, respectively), while in the subsequent year, reductions in such mortality were observed (P<.05 for all comparisons).
The absolute increased risk of death from cardiac events reported within the first year after discontinuation of HT was 4 deaths per 10,000 woman-years of exposure. The absolute risk of death from stroke was 5 additional events per 10,000 woman-years. This level of risk is considered to be rare.

How these data compare to those of other studiesIn contrast with these Finnish data, findings from the Women’s Health Initiative—the largest randomized trial of menopausal HT—do not indicate an increase in mortality or an increase in coronary heart or stroke events among women stopping HT.^1,2
It seems likely that limitations associated with the Finnish observational data account for this discordance. For example, Mikkola and colleagues did not know why women discontinued HT, raising the possibility that women with symptoms suggestive of CVD or development of new risk factors preferentially stopped HT, potentially introducing important bias into the Finnish analysis.

What this evidence means for practiceWomen and their clinicians should make decisions regarding whether to continue, reduce the dose, or discontinue HT through shared decision making, focusing on individual patient quality of life parameters as well as changing risk concerns related to such entities as cancer, CVD, and osteoporosis.³ Dramatic as they are, findings from this Finnish report should not impact how we counsel women regarding use or discontinuation of HT.
—Andrew M. Kaunitz, MD; JoAnn E. Manson, MD, DrPH; and Cynthia A. Stuenkel, MD

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

This recently published study from Finland generated headlines when its authors concluded that stopping HT elevates the risk of mortality from cardiovascular disease (CVD), including cardiac and cerebrovascular events. Using nationwide data, investigators compared the CVD mortality rate among women who discontinued HT during the years 1994 through 2009 (n = 332,202) with expected (not actual) CVD mortality rates in the background population.
Within the first year after HT discontinuation, elevations in death rates from cardiac events and stroke were noted (standardized mortality ratio, 1.26 and 1.63, respectively), while in the subsequent year, reductions in such mortality were observed (P<.05 for all comparisons).
The absolute increased risk of death from cardiac events reported within the first year after discontinuation of HT was 4 deaths per 10,000 woman-years of exposure. The absolute risk of death from stroke was 5 additional events per 10,000 woman-years. This level of risk is considered to be rare.

How these data compare to those of other studiesIn contrast with these Finnish data, findings from the Women’s Health Initiative—the largest randomized trial of menopausal HT—do not indicate an increase in mortality or an increase in coronary heart or stroke events among women stopping HT.^1,2
It seems likely that limitations associated with the Finnish observational data account for this discordance. For example, Mikkola and colleagues did not know why women discontinued HT, raising the possibility that women with symptoms suggestive of CVD or development of new risk factors preferentially stopped HT, potentially introducing important bias into the Finnish analysis.

What this evidence means for practiceWomen and their clinicians should make decisions regarding whether to continue, reduce the dose, or discontinue HT through shared decision making, focusing on individual patient quality of life parameters as well as changing risk concerns related to such entities as cancer, CVD, and osteoporosis.³ Dramatic as they are, findings from this Finnish report should not impact how we counsel women regarding use or discontinuation of HT.
—Andrew M. Kaunitz, MD; JoAnn E. Manson, MD, DrPH; and Cynthia A. Stuenkel, MD

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

This recently published study from Finland generated headlines when its authors concluded that stopping HT elevates the risk of mortality from cardiovascular disease (CVD), including cardiac and cerebrovascular events. Using nationwide data, investigators compared the CVD mortality rate among women who discontinued HT during the years 1994 through 2009 (n = 332,202) with expected (not actual) CVD mortality rates in the background population.
Within the first year after HT discontinuation, elevations in death rates from cardiac events and stroke were noted (standardized mortality ratio, 1.26 and 1.63, respectively), while in the subsequent year, reductions in such mortality were observed (P<.05 for all comparisons).
The absolute increased risk of death from cardiac events reported within the first year after discontinuation of HT was 4 deaths per 10,000 woman-years of exposure. The absolute risk of death from stroke was 5 additional events per 10,000 woman-years. This level of risk is considered to be rare.

How these data compare to those of other studiesIn contrast with these Finnish data, findings from the Women’s Health Initiative—the largest randomized trial of menopausal HT—do not indicate an increase in mortality or an increase in coronary heart or stroke events among women stopping HT.^1,2
It seems likely that limitations associated with the Finnish observational data account for this discordance. For example, Mikkola and colleagues did not know why women discontinued HT, raising the possibility that women with symptoms suggestive of CVD or development of new risk factors preferentially stopped HT, potentially introducing important bias into the Finnish analysis.

What this evidence means for practiceWomen and their clinicians should make decisions regarding whether to continue, reduce the dose, or discontinue HT through shared decision making, focusing on individual patient quality of life parameters as well as changing risk concerns related to such entities as cancer, CVD, and osteoporosis.³ Dramatic as they are, findings from this Finnish report should not impact how we counsel women regarding use or discontinuation of HT.
—Andrew M. Kaunitz, MD; JoAnn E. Manson, MD, DrPH; and Cynthia A. Stuenkel, MD

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Patient denies consent to endometriosis treatment
A woman underwent laparoscopic surgery to remove an ovarian cyst. During surgery, the gynecologist found endometriosis and used electrosurgery to destroy the implants. Following extensive electrosurgery, a hemorrhage occurred. The gynecologist placed 5 large clips to control bleeding. The patient was discharged. When she returned to the hospital in pain, she was sent home again. She visited another emergency department (ED), where a clip was found to have blocked a ureter. She underwent ureteroneocystostomy to repair the damage. The patient now reports incontinence, a ligated ureter, and extensive scar tissue, which may keep her from being able to become pregnant.

Patient’s claim She only consented to ovarian cyst removal, not to any other procedures. The gynecologist was negligent in performing electrosurgery and placing the clips. A urologist should have checked for injury.

Physician’s defense When a patient agrees to laparoscopic surgery, she also agrees to exploratory abdominal surgery. The gynecologist performs electrosurgery to treat endometriosis in 30% to 60% of her surgical cases. Electrosurgery was essential to stop the patient’s pain. The clips were carefully placed when treating the hemorrhage.

Verdict A $206,886 California verdict was returned against the gynecologist.

Eclampsia, death: $6.9M settlement
A mother delivered a healthy baby on May 21. Twice in the week following delivery, she returned to the ED reporting shortness of breath, swollen legs, and elevated blood pressure. Pulmonary embolism was excluded both times. After the second visit, she was discharged with a diagnosis of shortness of breath of unknown etiology. The patient’s ObGyn was not contacted nor was urinalysis performed. On June 1, she suffered seizures and brain injury; she died on June 10.

Estate’s claim The ED physicians failed to diagnose and treat eclampsia.

Defendant’s defense The case was settled early in the trial.

Verdict A $6.9 million Illinois settlement was reached with the hospital.

Child has CP: $8M settlement
At 40 1/7 weeks’ gestation, labor was induced in an obese woman who had a heart condition. Over the next 36 hours, dinoprostone and oxytocin were administered, but her cervix only dilated to 2 cm. Two days later, the fetal heart rate reached 160 bpm. The ObGyn ordered terbutaline in anticipation of cesarean delivery, but he did not come to the hospital. The fetal heart rate continued to rise and then bradycardia occurred. When notified, the ObGyn came to the hospital for an emergency cesarean delivery. The child was severely depressed at birth with Apgar scores of 0, 1, and 2 at 1, 5, and 10 minutes, respectively. Magnetic resonance imaging at 23 days showed distinct hypoxic ischemic injury in the infant. Cerebral palsy was later diagnosed. The child is nonambulatory with significant cognitive impairment.

Parents’ claim Failure to perform cesarean delivery in a timely manner caused injury to the child.

Defendant’s defense The case was settled during the trial.

Verdict An $8 million Wisconsin settlement was reached with the medical center and physician group.

Infant has a stroke: $3M settlement
A 26-year-old diabetic woman was referred to a maternal-fetal medicine (MFM) specialist. She had been hospitalized for nausea and dehydration several times during her pregnancy, but it appeared that fetal development was normal.

As labor progressed, fetal distress was diagnosed in the setting of low blood pressure. When notified, the MFM immediately ordered an emergency cesarean delivery. A few days after birth, it was determined that the child had a stroke in utero.

Parents’ claim Emergency cesarean delivery should have been performed earlier. Hospital staff did not communicate fetal distress to the MFM in a timely manner.

Defendant’s defense The case was settled at trial.

Verdict A $3 million Connecticut settlement was reached with the hospital.

Patient denies consent to endometriosis treatment
A woman underwent laparoscopic surgery to remove an ovarian cyst. During surgery, the gynecologist found endometriosis and used electrosurgery to destroy the implants. Following extensive electrosurgery, a hemorrhage occurred. The gynecologist placed 5 large clips to control bleeding. The patient was discharged. When she returned to the hospital in pain, she was sent home again. She visited another emergency department (ED), where a clip was found to have blocked a ureter. She underwent ureteroneocystostomy to repair the damage. The patient now reports incontinence, a ligated ureter, and extensive scar tissue, which may keep her from being able to become pregnant.

Patient’s claim She only consented to ovarian cyst removal, not to any other procedures. The gynecologist was negligent in performing electrosurgery and placing the clips. A urologist should have checked for injury.

Physician’s defense When a patient agrees to laparoscopic surgery, she also agrees to exploratory abdominal surgery. The gynecologist performs electrosurgery to treat endometriosis in 30% to 60% of her surgical cases. Electrosurgery was essential to stop the patient’s pain. The clips were carefully placed when treating the hemorrhage.

Verdict A $206,886 California verdict was returned against the gynecologist.

Eclampsia, death: $6.9M settlement
A mother delivered a healthy baby on May 21. Twice in the week following delivery, she returned to the ED reporting shortness of breath, swollen legs, and elevated blood pressure. Pulmonary embolism was excluded both times. After the second visit, she was discharged with a diagnosis of shortness of breath of unknown etiology. The patient’s ObGyn was not contacted nor was urinalysis performed. On June 1, she suffered seizures and brain injury; she died on June 10.

Estate’s claim The ED physicians failed to diagnose and treat eclampsia.

Defendant’s defense The case was settled early in the trial.

Verdict A $6.9 million Illinois settlement was reached with the hospital.

Child has CP: $8M settlement
At 40 1/7 weeks’ gestation, labor was induced in an obese woman who had a heart condition. Over the next 36 hours, dinoprostone and oxytocin were administered, but her cervix only dilated to 2 cm. Two days later, the fetal heart rate reached 160 bpm. The ObGyn ordered terbutaline in anticipation of cesarean delivery, but he did not come to the hospital. The fetal heart rate continued to rise and then bradycardia occurred. When notified, the ObGyn came to the hospital for an emergency cesarean delivery. The child was severely depressed at birth with Apgar scores of 0, 1, and 2 at 1, 5, and 10 minutes, respectively. Magnetic resonance imaging at 23 days showed distinct hypoxic ischemic injury in the infant. Cerebral palsy was later diagnosed. The child is nonambulatory with significant cognitive impairment.

Parents’ claim Failure to perform cesarean delivery in a timely manner caused injury to the child.

Defendant’s defense The case was settled during the trial.

Verdict An $8 million Wisconsin settlement was reached with the medical center and physician group.

Infant has a stroke: $3M settlement
A 26-year-old diabetic woman was referred to a maternal-fetal medicine (MFM) specialist. She had been hospitalized for nausea and dehydration several times during her pregnancy, but it appeared that fetal development was normal.

As labor progressed, fetal distress was diagnosed in the setting of low blood pressure. When notified, the MFM immediately ordered an emergency cesarean delivery. A few days after birth, it was determined that the child had a stroke in utero.

Parents’ claim Emergency cesarean delivery should have been performed earlier. Hospital staff did not communicate fetal distress to the MFM in a timely manner.

Defendant’s defense The case was settled at trial.

Verdict A $3 million Connecticut settlement was reached with the hospital.

Patient denies consent to endometriosis treatment
A woman underwent laparoscopic surgery to remove an ovarian cyst. During surgery, the gynecologist found endometriosis and used electrosurgery to destroy the implants. Following extensive electrosurgery, a hemorrhage occurred. The gynecologist placed 5 large clips to control bleeding. The patient was discharged. When she returned to the hospital in pain, she was sent home again. She visited another emergency department (ED), where a clip was found to have blocked a ureter. She underwent ureteroneocystostomy to repair the damage. The patient now reports incontinence, a ligated ureter, and extensive scar tissue, which may keep her from being able to become pregnant.

Patient’s claim She only consented to ovarian cyst removal, not to any other procedures. The gynecologist was negligent in performing electrosurgery and placing the clips. A urologist should have checked for injury.

Physician’s defense When a patient agrees to laparoscopic surgery, she also agrees to exploratory abdominal surgery. The gynecologist performs electrosurgery to treat endometriosis in 30% to 60% of her surgical cases. Electrosurgery was essential to stop the patient’s pain. The clips were carefully placed when treating the hemorrhage.

Verdict A $206,886 California verdict was returned against the gynecologist.

Eclampsia, death: $6.9M settlement
A mother delivered a healthy baby on May 21. Twice in the week following delivery, she returned to the ED reporting shortness of breath, swollen legs, and elevated blood pressure. Pulmonary embolism was excluded both times. After the second visit, she was discharged with a diagnosis of shortness of breath of unknown etiology. The patient’s ObGyn was not contacted nor was urinalysis performed. On June 1, she suffered seizures and brain injury; she died on June 10.

Estate’s claim The ED physicians failed to diagnose and treat eclampsia.

Defendant’s defense The case was settled early in the trial.

Verdict A $6.9 million Illinois settlement was reached with the hospital.

Child has CP: $8M settlement
At 40 1/7 weeks’ gestation, labor was induced in an obese woman who had a heart condition. Over the next 36 hours, dinoprostone and oxytocin were administered, but her cervix only dilated to 2 cm. Two days later, the fetal heart rate reached 160 bpm. The ObGyn ordered terbutaline in anticipation of cesarean delivery, but he did not come to the hospital. The fetal heart rate continued to rise and then bradycardia occurred. When notified, the ObGyn came to the hospital for an emergency cesarean delivery. The child was severely depressed at birth with Apgar scores of 0, 1, and 2 at 1, 5, and 10 minutes, respectively. Magnetic resonance imaging at 23 days showed distinct hypoxic ischemic injury in the infant. Cerebral palsy was later diagnosed. The child is nonambulatory with significant cognitive impairment.

Parents’ claim Failure to perform cesarean delivery in a timely manner caused injury to the child.

Defendant’s defense The case was settled during the trial.

Verdict An $8 million Wisconsin settlement was reached with the medical center and physician group.

Infant has a stroke: $3M settlement
A 26-year-old diabetic woman was referred to a maternal-fetal medicine (MFM) specialist. She had been hospitalized for nausea and dehydration several times during her pregnancy, but it appeared that fetal development was normal.

As labor progressed, fetal distress was diagnosed in the setting of low blood pressure. When notified, the MFM immediately ordered an emergency cesarean delivery. A few days after birth, it was determined that the child had a stroke in utero.

Parents’ claim Emergency cesarean delivery should have been performed earlier. Hospital staff did not communicate fetal distress to the MFM in a timely manner.

Defendant’s defense The case was settled at trial.

Verdict A $3 million Connecticut settlement was reached with the hospital.

When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

• traditional minimally invasive hysterectomy (n = 61) or
• robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

• traditional minimally invasive hysterectomy (n = 61) or
• robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

When investigators compared the cost of vaginal hysterectomy with robot-assisted laparoscopic hysterectomy head to head, they found hospital costs of $4,579 and $7,059, respectively, with no other significant differences between the approaches. Accordingly, they concluded that vaginal hysterectomy should be the “first-choice” approach when it is feasible.

The randomized controlled trial by Lönnerfors and colleagues also compared “traditional” minimally invasive hysterectomy (vaginal or laparoscopic approach) with robot-assisted hysterectomy in 122 women undergoing hysterectomy for benign conditions. Women with a uterine size of 16 gestational weeks or smaller were randomly allocated to:

• traditional minimally invasive hysterectomy (n = 61) or
• robotic assisted hysterectomy (n = 61).

In the traditional group, vaginal hysterectomy was the first-choice approach when it was feasible; otherwise, laparoscopic hysterectomy was performed. Vaginal hysterectomy was possible in 41% of cases in this group.

When costs for vaginal and laparoscopic approaches were consolidated and compared with the cost of the robot-assisted approach, the differential was $993 for the robotic approach when the robot was considered a preexisting investment. The hospital cost increased by $1,607 for the robotic approach when investment costs and maintenance expenses were included.

When laparoscopic hysterectomy was compared directly with robot-assisted hysterectomy, costs were similar ($7,016 vs $7,059, respectively) when the robot was considered a preexisting investment, and the robotic approach was associated with less blood loss and fewer postoperative complications.

Investigators noted that: “per-protocol analysis indicates that laparoscopic and robotic-assisted hysterectomy can be performed at similar hospital cost because of higher robot capacity that entails excluding the cost of investment and maintenance, i.e., the basic cost of the robot. This cost differs among institutions, depending on the number of procedures performed; however, the difference becomes less pronounced when 300 to 400 procedures or more are performed annually and the cost for instruments and disposables accounts for most of the cost of the procedure.”

This randomized controlled trial was awarded the Robert B. Hunt Award at the 2015 AAGL Global Congress in Las Vegas as the best paper published over the past year in the Journal of Minimally Invasive Gynecology.

When investigators from the Penn State Milton S. Hershey Medical Center randomly allocated 144 women to robot-assisted or standard laparoscopic hysterectomy (n = 72 in each arm) and recorded complications for 12 weeks, they found no significant differences between groups in estimated blood loss.¹ In addition, mean operative times (surgeon incision to surgeon stop, including docking in the robot-assisted group) were similar (73.9 min for robot-assisted surgery vs 74.9 min for standard laparoscopy), as were complication rates. In this trial, operative time was the primary outcome.

Pain was assessed at 2 postoperative hours and was found to be similar between groups.

Two intraoperative complications occurred in the robot-assisted group, compared with none for standard laparoscopy (P = .50). Six postoperative complications occurred in the robot-assisted group, compared with 9 in the standard laparoscopy group (P = 0.58).

Complications included: a need for reoperation/readmission (2 patients in each group; P = 1.00), infection (1 patient in each group; P = 1.00), hemorrhage/transfusion (4 in the standard laparoscopy group; P = 0.12), and vaginal cuff dehiscence (2 in the robot-assisted group vs 1 for standard laparoscopy; P = 1.00).

Investigators concluded that robot-assisted hysterectomy is “noninferior” to standard laparoscopy with regard to operative time when it is performed by experienced minimally invasive surgeons.

Gerald J. Harkins, MD, an author and primary surgeon of the trial, notes that it is the first randomized comparison involving surgeons with expertise in both robot-assisted and standard laparoscopic hysterectomy. As such, its findings represent Level I evidence. Dr. Harkins had completed more than 600 robot-assisted cases prior to initiation of the trial.

Cost was not analyzed in this study, the abstract of which won the Jay M. Cooper Award as the best paper on minimally invasive gynecology by a fellow and was presented on November 17 at the AAGL annual meeting in Las Vegas.

When investigators from the Penn State Milton S. Hershey Medical Center randomly allocated 144 women to robot-assisted or standard laparoscopic hysterectomy (n = 72 in each arm) and recorded complications for 12 weeks, they found no significant differences between groups in estimated blood loss.¹ In addition, mean operative times (surgeon incision to surgeon stop, including docking in the robot-assisted group) were similar (73.9 min for robot-assisted surgery vs 74.9 min for standard laparoscopy), as were complication rates. In this trial, operative time was the primary outcome.

Pain was assessed at 2 postoperative hours and was found to be similar between groups.

Two intraoperative complications occurred in the robot-assisted group, compared with none for standard laparoscopy (P = .50). Six postoperative complications occurred in the robot-assisted group, compared with 9 in the standard laparoscopy group (P = 0.58).

Complications included: a need for reoperation/readmission (2 patients in each group; P = 1.00), infection (1 patient in each group; P = 1.00), hemorrhage/transfusion (4 in the standard laparoscopy group; P = 0.12), and vaginal cuff dehiscence (2 in the robot-assisted group vs 1 for standard laparoscopy; P = 1.00).

Investigators concluded that robot-assisted hysterectomy is “noninferior” to standard laparoscopy with regard to operative time when it is performed by experienced minimally invasive surgeons.

Gerald J. Harkins, MD, an author and primary surgeon of the trial, notes that it is the first randomized comparison involving surgeons with expertise in both robot-assisted and standard laparoscopic hysterectomy. As such, its findings represent Level I evidence. Dr. Harkins had completed more than 600 robot-assisted cases prior to initiation of the trial.

Cost was not analyzed in this study, the abstract of which won the Jay M. Cooper Award as the best paper on minimally invasive gynecology by a fellow and was presented on November 17 at the AAGL annual meeting in Las Vegas.

When investigators from the Penn State Milton S. Hershey Medical Center randomly allocated 144 women to robot-assisted or standard laparoscopic hysterectomy (n = 72 in each arm) and recorded complications for 12 weeks, they found no significant differences between groups in estimated blood loss.¹ In addition, mean operative times (surgeon incision to surgeon stop, including docking in the robot-assisted group) were similar (73.9 min for robot-assisted surgery vs 74.9 min for standard laparoscopy), as were complication rates. In this trial, operative time was the primary outcome.

Pain was assessed at 2 postoperative hours and was found to be similar between groups.

Two intraoperative complications occurred in the robot-assisted group, compared with none for standard laparoscopy (P = .50). Six postoperative complications occurred in the robot-assisted group, compared with 9 in the standard laparoscopy group (P = 0.58).

Complications included: a need for reoperation/readmission (2 patients in each group; P = 1.00), infection (1 patient in each group; P = 1.00), hemorrhage/transfusion (4 in the standard laparoscopy group; P = 0.12), and vaginal cuff dehiscence (2 in the robot-assisted group vs 1 for standard laparoscopy; P = 1.00).

Investigators concluded that robot-assisted hysterectomy is “noninferior” to standard laparoscopy with regard to operative time when it is performed by experienced minimally invasive surgeons.

Gerald J. Harkins, MD, an author and primary surgeon of the trial, notes that it is the first randomized comparison involving surgeons with expertise in both robot-assisted and standard laparoscopic hysterectomy. As such, its findings represent Level I evidence. Dr. Harkins had completed more than 600 robot-assisted cases prior to initiation of the trial.

Cost was not analyzed in this study, the abstract of which won the Jay M. Cooper Award as the best paper on minimally invasive gynecology by a fellow and was presented on November 17 at the AAGL annual meeting in Las Vegas.

The rate of congenital syphilis increased to 11.6 cases per 100,000 live births in 2014 in the United States—the highest rate documented since 2001, according to a new report from the Centers for Disease Control and Prevention (CDC).¹ The increase in the rate of congenital syphilis reflects a rise in the rate of primary and secondary syphilis among US women, from 0.9 to 1.1 cases per 100,000 women, during the same period.¹

The rate of congenital syphilis had declined between 2008 and 2012, from 10.5 cases to 8.4 cases per 100,000 live births.

Congenital syphilis occurs when an infected mother transmits the disease to her fetus during pregnancy. Among the adverse effects of congenital syphilis are deformities, stillbirth, and early infant death. “However, among mothers identified with syphilis who deliver past 20 weeks’ gestation, treatment with penicillin at least 30 days before delivery is 98% effective at preventing [congenital syphilis],” the CDC report notes.¹

For the purposes of the CDC report, congenital syphilis includes “both infants and stillbirths with clinical evidence” of the disease, “as well as those infants and stillbirths born to mothers with untreated or inadequately treated syphilis, regardless of the infant’s manifestation of clinical disease.”¹

CDC recommendations
The CDC notes that most of the increases in the rates of maternal and congenital syphilis likely stem from inadequate prenatal care.

“A large percentage of [congenital syphilis] cases continue to be attributable to a lack of prenatal care; even among those receiving some prenatal care, the detection and treatment of maternal syphilis is often not early enough….At particular risk are those who are uninsured or underinsured and those with substance use issues.”¹

Among the recommendations of the CDC:

• Screen all pregnant women for syphilis at their first prenatal visit.
• Screen women at elevated risk for syphilis, as well as those who live in “high-morbidity geographic areas” at the beginning of the third trimester and again at delivery.
• In cases where prenatal care has been lacking, screen the woman for syphilis using a rapid plasma reagin (RPR) card and treat the patient who tests positive at the time the pregnancy is confirmed.
• Do not discharge an infant from the hospital unless the syphilis serologic status of the mother has been tested at least once during pregnancy and, preferably, again at delivery (in high-risk cases).
• Test any woman who delivers a stillborn infant for syphilis.

The rate of congenital syphilis increased to 11.6 cases per 100,000 live births in 2014 in the United States—the highest rate documented since 2001, according to a new report from the Centers for Disease Control and Prevention (CDC).¹ The increase in the rate of congenital syphilis reflects a rise in the rate of primary and secondary syphilis among US women, from 0.9 to 1.1 cases per 100,000 women, during the same period.¹

The rate of congenital syphilis had declined between 2008 and 2012, from 10.5 cases to 8.4 cases per 100,000 live births.

Congenital syphilis occurs when an infected mother transmits the disease to her fetus during pregnancy. Among the adverse effects of congenital syphilis are deformities, stillbirth, and early infant death. “However, among mothers identified with syphilis who deliver past 20 weeks’ gestation, treatment with penicillin at least 30 days before delivery is 98% effective at preventing [congenital syphilis],” the CDC report notes.¹

For the purposes of the CDC report, congenital syphilis includes “both infants and stillbirths with clinical evidence” of the disease, “as well as those infants and stillbirths born to mothers with untreated or inadequately treated syphilis, regardless of the infant’s manifestation of clinical disease.”¹

CDC recommendations
The CDC notes that most of the increases in the rates of maternal and congenital syphilis likely stem from inadequate prenatal care.

“A large percentage of [congenital syphilis] cases continue to be attributable to a lack of prenatal care; even among those receiving some prenatal care, the detection and treatment of maternal syphilis is often not early enough….At particular risk are those who are uninsured or underinsured and those with substance use issues.”¹

Among the recommendations of the CDC:

• Screen all pregnant women for syphilis at their first prenatal visit.
• Screen women at elevated risk for syphilis, as well as those who live in “high-morbidity geographic areas” at the beginning of the third trimester and again at delivery.
• In cases where prenatal care has been lacking, screen the woman for syphilis using a rapid plasma reagin (RPR) card and treat the patient who tests positive at the time the pregnancy is confirmed.
• Do not discharge an infant from the hospital unless the syphilis serologic status of the mother has been tested at least once during pregnancy and, preferably, again at delivery (in high-risk cases).
• Test any woman who delivers a stillborn infant for syphilis.

The rate of congenital syphilis increased to 11.6 cases per 100,000 live births in 2014 in the United States—the highest rate documented since 2001, according to a new report from the Centers for Disease Control and Prevention (CDC).¹ The increase in the rate of congenital syphilis reflects a rise in the rate of primary and secondary syphilis among US women, from 0.9 to 1.1 cases per 100,000 women, during the same period.¹

The rate of congenital syphilis had declined between 2008 and 2012, from 10.5 cases to 8.4 cases per 100,000 live births.

Congenital syphilis occurs when an infected mother transmits the disease to her fetus during pregnancy. Among the adverse effects of congenital syphilis are deformities, stillbirth, and early infant death. “However, among mothers identified with syphilis who deliver past 20 weeks’ gestation, treatment with penicillin at least 30 days before delivery is 98% effective at preventing [congenital syphilis],” the CDC report notes.¹

For the purposes of the CDC report, congenital syphilis includes “both infants and stillbirths with clinical evidence” of the disease, “as well as those infants and stillbirths born to mothers with untreated or inadequately treated syphilis, regardless of the infant’s manifestation of clinical disease.”¹

CDC recommendations
The CDC notes that most of the increases in the rates of maternal and congenital syphilis likely stem from inadequate prenatal care.

“A large percentage of [congenital syphilis] cases continue to be attributable to a lack of prenatal care; even among those receiving some prenatal care, the detection and treatment of maternal syphilis is often not early enough….At particular risk are those who are uninsured or underinsured and those with substance use issues.”¹

Among the recommendations of the CDC:

• Screen all pregnant women for syphilis at their first prenatal visit.
• Screen women at elevated risk for syphilis, as well as those who live in “high-morbidity geographic areas” at the beginning of the third trimester and again at delivery.
• In cases where prenatal care has been lacking, screen the woman for syphilis using a rapid plasma reagin (RPR) card and treat the patient who tests positive at the time the pregnancy is confirmed.
• Do not discharge an infant from the hospital unless the syphilis serologic status of the mother has been tested at least once during pregnancy and, preferably, again at delivery (in high-risk cases).
• Test any woman who delivers a stillborn infant for syphilis.

Tune in daily for social media coverage of AAGL 2015 from OBG Management and ObGyn News. Share your thoughts with us, and we may highlight them below. Thank you for your social contributions!

Tune in daily for social media coverage of AAGL 2015 from OBG Management and ObGyn News. Share your thoughts with us, and we may highlight them below. Thank you for your social contributions!

Tune in daily for social media coverage of AAGL 2015 from OBG Management and ObGyn News. Share your thoughts with us, and we may highlight them below. Thank you for your social contributions!