Re: Circumcision analgesia
From: Meenan, Anna (annam@uic.edu)
Wed Dec 17 12:43:28 2008
Our hospital mandates analgesia for circs, but
includes 40 mg of acetaminaphen one hour before
the procedure as adequate analgesia. LOL. I
think they are basically just caving to the Men
of Steel who don't want to ask someone to teach
them how to do a dorsal nerve block.
BTW, for anyone out there who doesn't know how,
it is 2 sub-Q injections of 1% lidocaine without
epinephrine, 0.4 cc each, at 10 o'clock and 2
o'clock at the base of the penis. Wait at least
3 minutes, preferably 5, before starting the
procedure. Because I am impatient when I have
nothing to occupy my hands, i do the injections
first with an alcohol wipe of the skin (it is
just a sub-q injection), then I scrub and drape
the kid, check out my instuments and arrange
them, which allows the block time to work. The
injections go sub-q, directly over the nerves as
they run out along the penis. If you inject
upwards into the suprapubic fat pad, the lido
dissipates there and does not do its job.
Ask any 3rd-year FP resident to show you if you
never learned how. That's who taught me.
Anna Meenan, MD
>Our Dept. recently came out with recommendations
>(mandate) that all circs will now be done with
>local
>anesthesia. ie either dorsal nerve block or
>subcutaneous ring block. I think it is a good
>idea.
>Anyone else have dept requiring local anesthesia for circs?
>
>Date: Wed, 17 Dec 2008 12:47:33 -0600
>From: agfolley@hotmail.com
>To: ob-gyn-l@mail.obgyn.net
>Subject: RE: Progesterone and short cervix
>
>.ExternalClass .EC_hmmessage P {padding:0px;}
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>
>The Use of Progesterone for Prevention of
>
>Preterm Birth
>
>Abstract
>
>Objective: To introduce new information on the use of progesterone
>
>to prevent premature labour and to provide guidance to obstetrical
>
>caregivers who counsel women on the merits of this choice
>
>Options: This discussion is limited to progesterone therapy for
>
>prevention of preterm labour (PTL) in women at increased risk of PTL.
>
>Evidence: A search of both Medline and the Cochrane Library
>
>identified the most relevant medical evidence. This document
>
>represents an abstraction of the evidence rather than a
>
>methodological review. The level of evidence and quality of
>
>recommendations are described using the criteria and
>
>classifications of the Canadian Task Force on Preventive Health
>
>Care (Table 1).
>
>Values: This update is the consensus of the Maternal Fetal Medicine
>
>Committee of the Society of Obstetricians and Gynaecologists of
>
>Canada (SOGC).
>
>Benefits, Harms, and Costs: Counselling the patient at increased
>
>risk for PTL should include consideration of the potential benefits
>
>of progesterone use and our lack of/limited knowledge of many
>
>neonatal outcomes and optimal dosing.
>
>Sponsor: Society of Obstetricians and Gynaecologists of Canada.
>
>Recommendations
>
>1. Women at risk for PTL should be encouraged to participate in
>
>studies on the role of progesterone in reducing the risks of preterm
>
>labour. (I-A)
>
>2. Women should be informed about the lack of available data for
>
>many neonatal outcome variables and about the lack of
>
>comparative data on dosing and route of administration. Women
>
>with short cervix should be informed of the single large RCT
>
>showing the benefit of progesterone in preventing PTL. (I-A)
>
>3. Women and their caregivers should be aware that a previous
>
>preterm labour and/or short cervix (< 15 mm at 22-26 weeks'
>
>gestation) on transvaginal ultrasound could be used as an
>
>indication for progesterone therapy. The therapy should be started
>
>after 20 weeks' gestation and stopped when the risk of prematurity
>
>is low. (I-A)
>
>4. On the basis of the data from the RCTs and meta-analysis, it is
>
>recommended that in cases where the clinician and the patient
>
>have opted for the use of progesterone the following dosages
>
>should be used:
>
>* For prevention of PTL in women with history of previous PTL:
>
>17 alpha- hydroxyprogesterone 250 mg IM weekly (IB) or
>
>progesterone 100 mg daily vaginally. (I-A)
>
>* For prevention of PTL in women with short cervix of 15 mm
>
>detected on transvaginal uktrasound at 22-26 weeks
>
>progesterone 200 mg daily vaginally. (I-A)
>
>J Obstet Gynaecol Can 2008;30(1):67-71
>
>Date: Wed, 17 Dec 2008 12:43:18 -0600
>From: agfolley@hotmail.com
>To: ob-gyn-l@mail.obgyn.net
>Subject: RE: Progesterone and short cervix
>
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>Vaginal Progesterone Gel May Improve Infant
>Outcomes and Reduce the Rate of Preterm Birth in
>Women with a Short Cervix in Mid-Pregnancy
>
>LIVINGSTON,
>N.J.--(<http://www.businesswire.com/>BUSINESS
>WIRE)--For the first time, data show a positive
>association between the use of vaginal
>progesterone and infants' overall health at
>birth. Babies born to women with high-risk
>pregnancies treated with PROCHIEVE® 8%
>(progesterone gel) appear to be less likely to
>need intensive care than babies born to mothers
>treated with placebo, Columbia Laboratories,
>Inc. (NASDAQ:CBRX) announced today. The data are
>published in the October issue of Ultrasound in
>Obstetrics & Gynecology (also known as The White
>Journal), the official publication of the
>International Society of Ultrasound in
>Obstetrics and Gynecology.
>Researchers conducted a secondary analysis of
>phase III data from the largest-ever singleton
>preterm birth prevention study with progesterone
>looking specifically at a group of 46 women with
>high-risk pregnancies because they had a short
>cervix (less than 2.8 cm measured by
>trans-vaginal ultrasound). This analysis shows
>several statistically significant findings,
>including:
>
>Only one out of six (16%) newborns of mothers
>treated with vaginal progesterone gel needed to
>be admitted to neonatal intensive care units
>compared to one out of two (52%) newborns of
>mothers treated with placebo (p-value of 0.016);
>and
>Infants born to mothers treated with vaginal
>progesterone gel who were admitted to intensive
>care units spent on average only one day in
>intensive care compared to more than two weeks
>for those babies of mothers who received placebo
>(p-value of 0.013).
>This is the first and only preterm birth
>prevention study that is associated with
>statistically significant improvements in
>clinically important measures of infant
>outcomes. Additional studies are being planned
>to repeat this unique finding.
>In addition, the analysis provided new insight
>into which women with high-risk pregnancies
>respond to treatment with vaginal progesterone
>gel. It showed that treatment with vaginal
>progesterone gel may reduce early preterm birth
>among women with a short cervix.
>"When looking at a sample of 46 women with a
>short cervix of less than 2.8 cm, zero of those
>who were started on vaginal progesterone gel
>between 18-to-22 weeks of gestational age
>delivered prior to 32 weeks of gestation, while
>almost one in three women (29.6 percent;
>p=0.014) with a shortened cervix given a placebo
>delivered prior to 32 weeks of gestation," said
>Emily DeFranco, DO, primary author of the study
>and clinical fellow of Maternal-Fetal Medicine,
>Department of Obstetrics and Gynecology, and
>Center for Preterm Birth Research at Washington
>University School of Medicine in St. Louis.
>"Additionally, the number of admissions and days
>spent in the neonatal intensive care unit,
>important measures of neonatal outcome, for
>babies whose moms were given vaginal
>progesterone gel were significantly lower than
>for those whose moms received placebo. We're
>excited about these promising clinical
>implications, especially if confirmed in a
>larger study."
>"Publishing these findings is an important step
>toward informing healthcare providers about the
>group of women who may benefit from vaginal
>progesterone by reducing their chances for
>having an early preterm birth," said study
>co-author John O'Brien, M.D., affiliated with
>Central Baptist Hospital, Lexington, KY. "There
>are currently no FDA-approved treatments
>available to help prevent preterm birth, so this
>research, combined with future studies, may lead
>to viable treatment options."
>The published subset of data is from a
>randomized, double-blind, placebo-controlled
>study -- the largest study to date evaluating
>the effect of progesterone on early preterm
>birth in singletons. The report on these data,
>entitled "Vaginal Progesterone Is Associated
>With a Decrease in Risk for Early Preterm Birth
>and Improved Neonatal Outcome in Women with a
>Short Cervix," is available at
><http://www3.interscience.wiley.com/cgi-bin/jhome/99020267>http://www3.interscience.wiley.com/cgi-bin/jhome/99020267.
>"Based on the statistically significant findings
>in the secondary analysis, we are moving forward
>with a follow-up study using PROCHIEVE 8%,"
>stated Robert S. Mills, president and chief
>executive officer of Columbia Laboratories. "It
>is estimated that of the more than 4.1 million
>live births in the U.S. each year, up to 30
>percent of pregnant mothers have a cervical
>length less than or equal to 3.0 centimeters in
>mid-pregnancy. This includes many women with
>first-time pregnancies, the group that has the
>largest number of premature babies each year. We
>look forward to publishing the results of the
>next study."
>A normal pregnancy is about 40 weeks. Preterm
>birth before 37 weeks gestation is a leading
>cause of infant and neonatal death, continues to
>rise, and occurs in more than 12 percent of
>pregnancies in the United States. The negative
>health effects of preterm birth go far beyond
>the first days of life; preterm birth is
>associated with a high prevalence of severe
>neurological deficits and developmental
>disabilities.
>These negative health outcomes have economic
>implications, as well. A 2005 March of Dimes
>study found that employers pay nearly 15 times
>more in direct healthcare coverage costs for
>babies born prematurely - in their first year of
>life - than for full term babies, with an
>average cost of $41,610 for a premature baby vs.
>$2,830 for a healthy, full-term baby. In a
>separate analysis, the March of Dimes estimates
>that in 2002, almost half of hospital charges
>for premature infants, or about $7.4 billion,
>were billed to employers and other private
>insurers. This estimate was derived using the
>Nationwide Inpatient Sample from the Agency for
>Healthcare Research and Quality.
>"Preterm birth has such a profound effect on
>both babies and their families that any research
>that can help us understand how to prevent
>preterm birth is a significant advance," said
>Susan Wysocki, RNC, NP, FAANP, president and
>chief executive officer National Association of
>Nurse Practitioners in Women's Health.
>The overall Phase III study, "Progesterone
>Vaginal Gel for the Reduction of Recurrent
>Preterm Birth: Primary Results from a
>Randomized, Double-blind, Placebo-controlled
>Trial," did not show a beneficial effect of
>progesterone treatment on reducing the frequency
>of preterm birth in a larger population of
>high-risk women identified with "only" a history
>of spontaneous preterm birth.
>Progesterone is a natural hormone found in all
>women, though levels of progesterone increase
>during pregnancy. Progesterone is also a
>well-established hormonal supplement required
>for successful infertility treatments.
>About PROCHIEVE 8%
>PROCHIEVE® 8% is natural progesterone
>FDA-approved for progesterone supplementation or
>replacement as part of Assisted Reproductive
>Technology (ART) treatment for infertile women
>with progesterone deficiency. Several trials
>showing these benefits have been published.
>PROCHIEVE 8% is safe for use during pregnancy,
>and has been safely used for a decade by tens of
>thousands of women globally to help sustain
>pregnancy in the first trimester. Its unique
>bioadhesive delivery system provides controlled
>and sustained release of progesterone directly
>where it is needed.
>The most common side effects of PROCHIEVE 8%
>include breast enlargement, constipation,
>somnolence, nausea, headache, and perineal pain.
>PROCHIEVE 8% is contraindicated in patients with
>active thrombophlebitis or thromboembolic
>disorders, or a history of hormone-associated
>thrombophlebitis or thromboembolic disorders,
>missed abortion, undiagnosed vaginal bleeding,
>liver dysfunction or disease, and known or
>suspected malignancy of the breast or genital
>organs. For more information, please visit
><http://www.prochieve8.com/>www.prochieve8.com.
>About Columbia Laboratories
>Columbia Laboratories, Inc. is a U.S.-based
>international pharmaceutical company dedicated
>to the development and commercialization of
>women's healthcare and endocrinology products
>that use its novel bioadhesive drug delivery
>technology. Columbia markets CRINONE® 8%
>(progesterone gel) and PROCHIEVE® 8%
>(progesterone gel) in the United States for
>progesterone supplementation as part of Assisted
>Reproductive Technology treatment for infertile
>women with progesterone deficiency, and
>PROCHIEVE® 4% (progesterone gel) for the
>treatment of secondary amenorrhea. The Company
>also markets STRIANT® (testosterone buccal
>system) for the treatment of hypogonadism in
>men. For more information, please visit
><http://www.columbialabs.com/>www.columbialabs.com.
>
>Date: Wed, 17 Dec 2008 12:38:04 -0600
>From: agfolley@hotmail.com
>To: ob-gyn-l@mail.obgyn.net
>Subject: RE: Progesterone and short cervix
>
>.ExternalClass .EC_hmmessage P {padding:0px;}
>.ExternalClass body.EC_hmmessage
>{font-size:10pt;font-family:Verdana;}
>
>Progesterone and the Risk of Preterm Birth among Women with a Short Cervix
>
>Eduardo B. Fonseca, M.D., Ebru Celik, M.D.,
>Mauro Parra, M.D., Mandeep Singh, M.D., Kypros
>H. Nicolaides, M.D., for the Fetal Medicine
>Foundation Second Trimester Screening Group
>
><http://content.nejm.org/cgi/content/abstract/357/5/462>Abstract
><http://content.nejm.org/cgi/reprint/357/5/462.pdf>PDF
><http://content.nejm.org/cgi/external_ref?link_type=pda_mms&doi=10.1056/NEJMoa067815>PDA
>Full Text
><http://content.nejm.org/cgi/slideshow/357/5/462>PowerPoint
>Slide Set
>
> <http://content.nejm.org/cgi/content/short/357/5/499>Editorial
> <http://content.nejm.org/cgi/content/short/357/5/499>by Thornton, J. G.
> <http://content.nejm.org/cgi/content/full/357/5/462#related_letters>Letters
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><http://content.nejm.org/cgi/external_ref?access_num=17671254&link_type=PUBMED>PubMed
>Citation
>ABSTRACT Background Previous randomized trials
>have shown that progesterone administration in
>women who previously delivered prematurely
>reduces the risk of recurrent premature
>delivery. Asymptomatic women found at
>midgestation to have a short cervix are at
>greatly increased risk for spontaneous early
>preterm delivery, and it is unknown whether
>progesterone reduces this risk in such women.
>Methods Cervical length was measured by
>transvaginal ultrasonography at a median of 22
>weeks of gestation (range, 20 to 25) in 24,620
>pregnant women seen for routine prenatal care.
>Cervical length was 15 mm or less in 413 of the
>women (1.7%), and 250 (60.5%) of these 413 women
>were randomly assigned to receive vaginal
>progesterone (200 mg each night) or placebo from
>24 to 34 weeks of gestation. The primary outcome
>was spontaneous delivery before 34 weeks.
>Results Spontaneous delivery before 34 weeks of
>gestation was less frequent in the progesterone
>group than in the placebo group (19.2% vs.
>34.4%; relative risk, 0.56; 95% confidence
>interval [CI], 0.36 to 0.86). Progesterone was
>associated with a nonsignificant reduction in
>neonatal morbidity (8.1% vs. 13.8%; relative
>risk, 0.59; 95% CI, 0.26 to 1.25; P=0.17). There
>were no serious adverse events associated with
>the use of progesterone.
>
>Conclusions In women with a short cervix,
>treatment with progesterone reduces the rate of
>spontaneous early preterm delivery.
>(ClinicalTrials.gov number, NCT00422526
><http://content.nejm.org/cgi/external_ref?access_num=NCT00422526&link_type=CLINTRIALGOV>[ClinicalTrials.gov]
>.)
>
>Prematurity is the leading cause of neonatal
>death and
>handicap.<http://content.nejm.org/cgi/content/full/357/5/462#R1>1
>Although all births before 37 weeks of gestation
>are defined as preterm, most damage and death
>occurs in infants delivered before 34
>weeks.<http://content.nejm.org/cgi/content/full/357/5/462#R2>2,<http://content.nejm.org/cgi/content/full/357/5/462#R3>3
>Improvements in neonatal care have led to higher
>rates of survival among very premature infants,
>but a major effect on the associated mortality
>and morbidity will be achieved only by better
>identification of women at high risk for preterm
>delivery and by development of an effective
>intervention to prevent this complication.
>
>The prophylactic administration of progesterone
>beginning in midgestation to women who
>previously had a preterm birth has been shown to
>halve the rate of
>recurrence.<http://content.nejm.org/cgi/content/full/357/5/462#R4>4,<http://content.nejm.org/cgi/content/full/357/5/462#R5>5,<http://content.nejm.org/cgi/content/full/357/5/462#R6>6
>However, a strategy in which therapeutic
>intervention is limited to women with a previous
>preterm delivery is likely to have a small
>effect on the overall rate of prematurity,
>because only about 10% of spontaneous early
>preterm births occur in women with this
>history.<http://content.nejm.org/cgi/content/full/357/5/462#R7>7
>A method that may better identify women at high
>risk with either singleton or twin pregnancies
>is ultrasonographic measurement of cervical
>length at 20 to 24 weeks of
>gestation.<http://content.nejm.org/cgi/content/full/357/5/462#R8>8,<http://content.nejm.org/cgi/content/full/357/5/462#R9>9,<http://content.nejm.org/cgi/content/full/357/5/462#R10>10
>Asymptomatic women found to have a cervical
>length of 15 mm or less are at greatly increased
>risk for spontaneous early preterm delivery. We
>designed a multicenter, randomized trial to
>evaluate the effect of vaginal progesterone on
>the incidence of spontaneous early preterm
>delivery in asymptomatic women found at routine
>mid-trimester screening to have a short cervix.
>
>Date: Tue, 16 Dec 2008 11:45:51 -0600
>From: rd.braun@gmail.com
>To: ob-gyn-l@mail.obgyn.net
>Subject: Re: Trouble with FP again
>
>I am giving GR in Dayton tomorrow. Topic:
>"Operative Vaginal Delivery". I may start by
>paraphrasing Antony.
>Friends Romans, Countrymen, I come to bury forceps, not to praise them.
>
>Dan
>
>On Tue, Dec 16, 2008 at 10:16 AM,
><<mailto:DoctorJoe@aol.com>DoctorJoe@aol.com>
>wrote:
>
>In a message dated 12/16/08 9:09:59 AM,
><mailto:evsono@pipeline.com>evsono@pipeline.com
>writes:
>
>In the US, Ob-Gyn's were trained to manage their own complications -
>bowel injuries, bladder injuries, etc. Over time, the medicolegal
>cancer spread insidiously so that consults are called routinely over
>things well within the purview of a trained Ob-Gyn.
>
>Well, like most everything else, I wouldn't
>blame it ALL on the lawyers. They aren't that
>original. Much of the blame lies on our own
>organizatons, with the advent of specialization,
>limited residency experience, etc.
>
>"We have met the enemy and he is us."
>
>Joe P.
>
com00000010>http://www.aol.com/?optin=new-dp&icid=aolcom40vanity&ncid==
emlcntaolcom00000010)
>
>--
>R. Daniel Braun, MD FACOG(L) ABMP CMTh
>Professor Emeritus
>Dept. of Obstetrics and Gynecology
>Indiana U. School of Medicine
>
>R. Daniel Braun
>
> "Science without Religion is LAME; Religion without Science is BLIND"
> Einstein 1941
>
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